- 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
- $457.09 / $588.84 / $1,318.26
| Professional | | $457.09 | $588.84 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $549.54 / $977.24
| Professional | | $489.78 | $549.54 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,071.52
| Professional | | $575.44 | $724.44 | $1,071.52 |
- 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
- $426.58 / $616.60 / $1,148.15
| Professional | | $426.58 | $616.60 | $1,148.15 |