- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $537.03 / $1,445.44
| Professional | | $426.58 | $537.03 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $537.03 / $891.25
| Professional | | $478.63 | $537.03 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $1,096.48
| Professional | | $602.56 | $741.31 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $602.56 / $1,174.90
| Professional | | $446.68 | $602.56 | $1,174.90 |