- 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
- $602.56 / $741.31 / $1,698.24
| Professional | | $602.56 | $741.31 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $645.65 / $1,071.52
| Professional | | $489.78 | $645.65 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $741.31 / $1,318.26
| Professional | | $89.13 | $741.31 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,471.29
| Facility | | $2,818.38 | $5,128.61 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $831.76 / $1,288.25
| Professional | | $562.34 | $831.76 | $1,288.25 |