- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,370.32 / $9,772.37
| Facility | | $3,981.07 | $5,370.32 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $912.01 / $2,238.72
| Professional | | $588.84 | $912.01 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $691.83 / $1,174.90
| Professional | | $512.86 | $691.83 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $891.25 / $1,479.11
| Professional | | $251.19 | $891.25 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,413.10 / $13,489.63
| Facility | | $3,715.35 | $7,413.10 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $1,412.54
| Professional | | $602.56 | $891.25 | $1,412.54 |