- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $1,949.84
| Professional | | $616.60 | $724.44 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $1,202.26
| Professional | | $645.65 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,479.11
| Professional | | $812.83 | $1,047.13 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,413.10 / $13,489.63
| Facility | | $3,715.35 | $7,413.10 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $851.14 / $1,548.82
| Professional | | $602.56 | $851.14 | $1,548.82 |