- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $2,041.74
| Professional | | $602.56 | $741.31 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $741.31 / $1,202.26
| Professional | | $630.96 | $741.31 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $1,513.56
| Professional | | $812.83 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $15,135.61
| Facility | | $3,235.94 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $1,584.89
| Professional | | $660.69 | $1,023.29 | $1,584.89 |