- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,801.89 / $3,981.07
| Facility | | $2,398.83 | $3,801.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $407.38 / $1,071.52
| Professional | | $213.80 | $407.38 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $331.13 / $512.86
| Professional | | $218.78 | $331.13 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $524.81 / $891.25
| Professional | | $338.84 | $524.81 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $436.52 / $794.33
| Professional | | $257.04 | $436.52 | $794.33 |