- 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
- $407.38 / $501.19 / $1,288.25
| Professional | | $407.38 | $501.19 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $524.81 / $851.14
| Professional | | $398.11 | $524.81 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $676.08 / $977.24
| Professional | | $478.63 | $676.08 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $6,025.60
| Facility | | $1,380.38 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $1,023.29
| Professional | | $389.05 | $562.34 | $1,023.29 |