- 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
- $691.83 / $870.96 / $2,238.72
| Professional | | $691.83 | $870.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $1,230.27
| Professional | | $562.34 | $758.58 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $933.25 / $1,513.56
| Professional | | $181.97 | $933.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $1,412.54
| Professional | | $645.65 | $912.01 | $1,412.54 |