- 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
- $831.76 / $954.99 / $2,570.40
| Professional | | $831.76 | $954.99 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $954.99 / $1,548.82
| Professional | | $812.83 | $954.99 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $1,949.84
| Professional | | $1,071.52 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,174.90 / $2,089.30
| Professional | | $794.33 | $1,174.90 | $2,089.30 |