- 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
- $707.95 / $851.14 / $2,137.96
| Professional | | $707.95 | $851.14 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $741.31 / $1,230.27
| Professional | | $549.54 | $741.31 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $954.99 / $1,548.82
| Professional | | $181.97 | $954.99 | $1,548.82 |
- 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
- $676.08 / $954.99 / $1,380.38
| Professional | | $676.08 | $954.99 | $1,380.38 |