- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,011.87 / $8,128.31
| Facility | | $3,162.28 | $5,011.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $501.19 / $1,348.96
| Professional | | $251.19 | $501.19 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $562.34 / $1,445.44
| Facility | | $316.23 | $562.34 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,737.80 / $6,918.31
| Facility | | $436.52 | $1,737.80 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,862.09 / $3,715.35
| Facility | | $602.56 | $1,862.09 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |