- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $741.31 / $1,949.84
| Professional | | $549.54 | $741.31 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $741.31 / $1,174.90
| Professional | | $645.65 | $741.31 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,513.56
| Professional | | $812.83 | $1,047.13 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,413.10 / $13,489.63
| Facility | | $3,715.35 | $7,413.10 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,584.89
| Professional | | $588.84 | $870.96 | $1,584.89 |