- 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 / $912.01 / $2,344.23
| Professional | | $616.60 | $912.01 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,412.54
| Professional | | $602.56 | $812.83 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,202.26 / $1,737.80
| Professional | | $512.86 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,023.29 / $1,778.28
| Professional | | $741.31 | $1,023.29 | $1,778.28 |