- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $489.78 / $1,148.15
| Professional | | $316.23 | $489.78 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $407.38 / $660.69
| Professional | | $263.03 | $407.38 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $660.69 / $1,096.48
| Professional | | $407.38 | $660.69 | $1,096.48 |
- 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
- $275.42 / $501.19 / $933.25
| Professional | | $275.42 | $501.19 | $933.25 |