- 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
- $724.44 / $812.83 / $2,137.96
| Professional | | $724.44 | $812.83 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,412.54
| Professional | | $691.83 | $812.83 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,659.59
| Professional | | $794.33 | $1,071.52 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $891.25 / $1,778.28
| Professional | | $562.34 | $891.25 | $1,778.28 |