- 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
- $338.84 / $616.60 / $1,584.89
| Professional | | $338.84 | $616.60 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $478.63 / $891.25
| Professional | | $407.38 | $478.63 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $741.31 / $1,096.48
| Professional | | $512.86 | $741.31 | $1,096.48 |
- 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
- $537.03 / $707.95 / $1,096.48
| Professional | | $537.03 | $707.95 | $1,096.48 |