- 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
- $331.13 / $588.84 / $1,513.56
| Professional | | $331.13 | $588.84 | $1,513.56 |
- 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
- $489.78 / $724.44 / $1,047.13
| Professional | | $489.78 | $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
- $489.78 / $676.08 / $1,023.29
| Professional | | $489.78 | $676.08 | $1,023.29 |