- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $870.96 / $2,238.72
| Professional | | $616.60 | $870.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,380.38
| Professional | | $630.96 | $831.76 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,071.52 / $1,698.24
| Professional | | $151.36 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,023.29 / $1,778.28
| Professional | | $707.95 | $1,023.29 | $1,778.28 |