- 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
- $575.44 / $691.83 / $1,862.09
| Professional | | $575.44 | $691.83 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $691.83 / $1,122.02
| Professional | | $588.84 | $691.83 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,380.38
| Professional | | $776.25 | $1,047.13 | $1,380.38 |
- 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
- $562.34 / $831.76 / $1,548.82
| Professional | | $562.34 | $831.76 | $1,548.82 |