- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $6,918.31
| Facility | | $1,258.93 | $1,513.56 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $831.76 / $1,819.70
| Professional | | $537.03 | $831.76 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $676.08 / $1,122.02
| Professional | | $512.86 | $676.08 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $724.44 / $1,380.38
| Professional | | $151.36 | $724.44 | $1,380.38 |
- 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
- $512.86 / $812.83 / $1,412.54
| Professional | | $512.86 | $812.83 | $1,412.54 |