- 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
- $436.52 / $794.33 / $1,905.46
| Professional | | $436.52 | $794.33 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $630.96 / $1,148.15
| Professional | | $537.03 | $630.96 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,380.38
| Professional | | $660.69 | $891.25 | $1,380.38 |
- 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
- $645.65 / $851.14 / $1,412.54
| Professional | | $645.65 | $851.14 | $1,412.54 |