- 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
- $707.95 / $977.24 / $1,995.26
| Professional | | $707.95 | $977.24 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $741.31 / $1,288.25
| Professional | | $562.34 | $741.31 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $851.14 / $1,513.56
| Professional | | $181.97 | $851.14 | $1,513.56 |
- 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
- $616.60 / $954.99 / $1,479.11
| Professional | | $616.60 | $954.99 | $1,479.11 |