- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $338.84 / $831.76
| Professional | | $295.12 | $338.84 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $346.74 / $575.44
| Professional | | $302.00 | $346.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $467.74 / $691.83
| Professional | | $380.19 | $467.74 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $724.44
| Professional | | $288.40 | $407.38 | $724.44 |