- 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
- $758.58 / $954.99 / $2,454.71
| Professional | | $758.58 | $954.99 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $1,348.96
| Professional | | $616.60 | $812.83 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,047.13 / $1,659.59
| Professional | | $181.97 | $1,047.13 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,548.82
| Professional | | $707.95 | $1,047.13 | $1,548.82 |