- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $3,981.07
| Facility | | $1,047.13 | $1,047.13 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $2,238.72
| Professional | | $691.83 | $812.83 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $1,318.26
| Professional | | $724.44 | $812.83 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $1,621.81
| Professional | | $912.01 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $954.99 / $1,819.70
| Professional | | $630.96 | $954.99 | $1,819.70 |