- 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
- $812.83 / $1,122.02 / $2,884.03
| Professional | | $812.83 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,778.28
| Professional | | $831.76 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,412.54 / $2,238.72
| Professional | | $151.36 | $1,412.54 | $2,238.72 |
- 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
- $851.14 / $1,348.96 / $2,290.87
| Professional | | $851.14 | $1,348.96 | $2,290.87 |