- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,466.84 / $5,888.44
| Facility | | $3,981.07 | $4,466.84 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $602.56 / $1,148.15
| Professional | | $416.87 | $602.56 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $575.44 / $912.01
| Professional | | $436.52 | $575.44 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,174.90 / $1,174.90
| Facility | | $676.08 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $691.83 / $1,318.26
| Professional | | $416.87 | $691.83 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,398.83 / $5,495.41
| Facility | | $794.33 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $588.84 / $1,071.52
| Professional | | $389.05 | $588.84 | $1,071.52 |