- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $501.19 / $1,318.26
| Professional | | $416.87 | $501.19 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $457.09 / $741.31
| Professional | | $338.84 | $457.09 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $549.54 / $912.01
| Professional | | $181.97 | $549.54 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $549.54 / $933.25
| Professional | | $389.05 | $549.54 | $933.25 |