- 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
- $691.83 / $912.01 / $2,137.96
| Professional | | $691.83 | $912.01 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $741.31 / $1,288.25
| Professional | | $562.34 | $741.31 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $912.01 / $1,548.82
| Professional | | $208.93 | $912.01 | $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
- $660.69 / $933.25 / $1,479.11
| Professional | | $660.69 | $933.25 | $1,479.11 |