- 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
- $512.86 / $954.99 / $2,290.87
| Professional | | $512.86 | $954.99 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $1,380.38
| Professional | | $660.69 | $776.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $1,659.59
| Professional | | $794.33 | $1,148.15 | $1,659.59 |
- 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
- $630.96 / $1,023.29 / $1,698.24
| Professional | | $630.96 | $1,023.29 | $1,698.24 |