- 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
- $407.38 / $724.44 / $1,023.29
| Professional | | $407.38 | $724.44 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $436.52 / $977.24
| Professional | | $371.54 | $436.52 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $676.08 / $1,318.26
| Professional | | $478.63 | $676.08 | $1,318.26 |
- 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
- $588.84 / $891.25 / $1,122.02
| Professional | | $588.84 | $891.25 | $1,122.02 |