- 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
- $676.08 / $891.25 / $2,290.87
| Professional | | $676.08 | $891.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $870.96 / $1,445.44
| Professional | | $776.25 | $870.96 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $1,819.70
| Professional | | $977.24 | $1,258.93 | $1,819.70 |
- 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
- $741.31 / $1,047.13 / $1,905.46
| Professional | | $741.31 | $1,047.13 | $1,905.46 |