- 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
- $467.74 / $691.83 / $1,479.11
| Professional | | $467.74 | $691.83 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $616.60 / $1,122.02
| Professional | | $457.09 | $616.60 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $1,380.38
| Professional | | $616.60 | $851.14 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,288.25
| Professional | | $478.63 | $741.31 | $1,288.25 |