- 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
- $426.58 / $616.60 / $1,737.80
| Professional | | $426.58 | $616.60 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $870.96
| Professional | | $398.11 | $537.03 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $794.33 / $1,318.26
| Professional | | $524.81 | $794.33 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $707.95 / $1,174.90
| Professional | | $416.87 | $707.95 | $1,174.90 |