- 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
- $288.40 / $562.34 / $1,348.96
| Professional | | $288.40 | $562.34 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $426.58 / $812.83
| Professional | | $363.08 | $426.58 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $616.60 / $954.99
| Professional | | $457.09 | $616.60 | $954.99 |
- 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
- $457.09 / $616.60 / $977.24
| Professional | | $457.09 | $616.60 | $977.24 |