- 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
- $489.78 / $549.54 / $1,513.56
| Professional | | $489.78 | $549.54 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $537.03 / $912.01
| Professional | | $478.63 | $537.03 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $1,445.44
| Professional | | $602.56 | $954.99 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,413.10 / $13,489.63
| Facility | | $3,715.35 | $7,413.10 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $1,258.93
| Professional | | $489.78 | $812.83 | $1,258.93 |