- 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
- $257.04 / $363.08 / $1,023.29
| Professional | | $257.04 | $363.08 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $331.13 / $616.60
| Professional | | $251.19 | $331.13 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $436.52 / $724.44
| Professional | | $181.97 | $436.52 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $426.58 / $741.31
| Professional | | $309.03 | $426.58 | $741.31 |