- 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
- $660.69 / $758.58 / $2,041.74
| Professional | | $660.69 | $758.58 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $758.58 / $1,258.93
| Professional | | $660.69 | $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
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $933.25 / $1,621.81
| Professional | | $630.96 | $933.25 | $1,621.81 |