- 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
- $478.63 / $741.31 / $1,819.70
| Professional | | $478.63 | $741.31 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $426.58 / $1,047.13
| Professional | | $363.08 | $426.58 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $794.33 / $1,096.48
| Professional | | $407.38 | $794.33 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $707.95 / $1,023.29
| Professional | | $501.19 | $707.95 | $1,023.29 |