- 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
- $660.69 / $933.25 / $2,041.74
| Professional | | $660.69 | $933.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,258.93
| Professional | | $645.65 | $758.58 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $1,548.82
| Professional | | $831.76 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,912.51
| Facility | | $2,570.40 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $1,621.81
| Professional | | $630.96 | $912.01 | $1,621.81 |