- 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
- $630.96 / $724.44 / $1,905.46
| Professional | | $630.96 | $724.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $724.44 / $1,202.26
| Professional | | $630.96 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,479.11
| Professional | | $794.33 | $1,023.29 | $1,479.11 |
- 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
- $602.56 / $851.14 / $1,548.82
| Professional | | $602.56 | $851.14 | $1,548.82 |