- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $851.14 / $2,041.74
| Professional | | $645.65 | $851.14 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,412.54
| Professional | | $630.96 | $851.14 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,698.24
| Professional | | $758.58 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $933.25 / $1,621.81
| Professional | | $616.60 | $933.25 | $1,621.81 |