- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,762.47 / $7,762.47
| Facility | | $3,467.37 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,737.80
| Professional | | $478.63 | $741.31 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $831.76
| Professional | | $426.58 | $575.44 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $660.69 / $1,230.27
| Professional | | $398.11 | $660.69 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $645.65 / $1,023.29
| Professional | | $416.87 | $645.65 | $1,023.29 |