- 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
- $478.63 / $912.01 / $1,230.27
| Professional | | $478.63 | $912.01 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $707.95 / $1,288.25
| Professional | | $602.56 | $707.95 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,584.89
| Professional | | $758.58 | $1,096.48 | $1,584.89 |
- 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
- $776.25 / $1,071.52 / $1,621.81
| Professional | | $776.25 | $1,071.52 | $1,621.81 |