- 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
- $549.54 / $812.83 / $2,041.74
| Professional | | $549.54 | $812.83 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,258.93
| Professional | | $549.54 | $724.44 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $831.76 / $1,548.82
| Professional | | $363.08 | $831.76 | $1,548.82 |
- 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
- $602.56 / $912.01 / $1,584.89
| Professional | | $602.56 | $912.01 | $1,584.89 |