- 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
- $416.87 / $575.44 / $1,318.26
| Professional | | $416.87 | $575.44 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $524.81 / $954.99
| Professional | | $398.11 | $524.81 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,148.15
| Professional | | $501.19 | $758.58 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,912.51
| Facility | | $2,570.40 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $645.65 / $1,174.90
| Professional | | $416.87 | $645.65 | $1,174.90 |