- 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
- $316.23 / $602.56 / $812.83
| Professional | | $316.23 | $602.56 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $467.74 / $831.76
| Professional | | $398.11 | $467.74 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $724.44 / $1,047.13
| Professional | | $501.19 | $724.44 | $1,047.13 |
- 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
- $512.86 / $691.83 / $1,071.52
| Professional | | $512.86 | $691.83 | $1,071.52 |