- 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
- $549.54 / $630.96 / $1,698.24
| Professional | | $549.54 | $630.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $630.96 / $1,047.13
| Professional | | $562.34 | $630.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $851.14 / $1,288.25
| Professional | | $707.95 | $851.14 | $1,288.25 |
- 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
- $489.78 / $724.44 / $1,380.38
| Professional | | $489.78 | $724.44 | $1,380.38 |