- 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
- $269.15 / $489.78 / $1,258.93
| Professional | | $269.15 | $489.78 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $398.11 / $776.25
| Professional | | $338.84 | $398.11 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $616.60 / $933.25
| Professional | | $426.58 | $616.60 | $933.25 |
- 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
- $436.52 / $575.44 / $912.01
| Professional | | $436.52 | $575.44 | $912.01 |