- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,897.79
| Facility | | $2,041.74 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $549.54 / $691.83
| Professional | | $416.87 | $549.54 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $2,041.74 / $4,897.79
| Facility | | $676.08 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $645.65 / $831.76
| Professional | | $537.03 | $645.65 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,890.45 / $6,025.60
| Facility | | $851.14 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $676.08 / $912.01
| Professional | | $562.34 | $676.08 | $912.01 |