- 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
- $263.03 / $512.86 / $1,258.93
| Professional | | $263.03 | $512.86 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $389.05 / $724.44
| Professional | | $331.13 | $389.05 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $870.96
| Professional | | $426.58 | $602.56 | $870.96 |
- 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
- $426.58 / $588.84 / $891.25
| Professional | | $426.58 | $588.84 | $891.25 |