- 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
- $380.19 / $602.56 / $1,348.96
| Professional | | $380.19 | $602.56 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $478.63 / $831.76
| Professional | | $354.81 | $478.63 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $602.56 / $1,023.29
| Professional | | $151.36 | $602.56 | $1,023.29 |
- 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
- $436.52 / $616.60 / $954.99
| Professional | | $436.52 | $616.60 | $954.99 |