- 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
- $630.96 / $812.83 / $1,905.46
| Professional | | $630.96 | $812.83 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $676.08 / $1,148.15
| Professional | | $512.86 | $676.08 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $870.96 / $1,380.38
| Professional | | $89.13 | $870.96 | $1,380.38 |
- 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
- $588.84 / $870.96 / $1,288.25
| Professional | | $588.84 | $870.96 | $1,288.25 |