- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $1,548.82
| Professional | | $537.03 | $758.58 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $575.44 / $1,096.48
| Professional | | $436.52 | $575.44 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $660.69 / $1,148.15
| Professional | | $208.93 | $660.69 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,912.51
| Facility | | $2,570.40 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $741.31 / $1,148.15
| Professional | | $501.19 | $741.31 | $1,148.15 |