- 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
- $457.09 / $562.34 / $1,412.54
| Professional | | $457.09 | $562.34 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $575.44 / $933.25
| Professional | | $457.09 | $575.44 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $741.31 / $1,096.48
| Professional | | $524.81 | $741.31 | $1,096.48 |
- 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
- $426.58 / $630.96 / $1,122.02
| Professional | | $426.58 | $630.96 | $1,122.02 |