- 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
- $354.81 / $549.54 / $1,174.90
| Professional | | $354.81 | $549.54 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $549.54 / $1,023.29
| Professional | | $363.08 | $549.54 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $660.69 / $1,122.02
| Professional | | $457.09 | $660.69 | $1,122.02 |
- 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
- $354.81 / $562.34 / $1,174.90
| Professional | | $354.81 | $562.34 | $1,174.90 |