- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,165.95 / $9,772.37
| Facility | | $3,715.35 | $6,165.95 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $616.60 / $1,202.26
| Professional | | $407.38 | $616.60 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $891.25
| Professional | | $389.05 | $512.86 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $691.83 / $1,174.90
| Professional | | $151.36 | $691.83 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,128.31
| Facility | | $2,570.40 | $4,677.35 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $645.65 / $1,047.13
| Professional | | $407.38 | $645.65 | $1,047.13 |