- 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
- $467.74 / $575.44 / $1,548.82
| Professional | | $467.74 | $575.44 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $954.99
| Professional | | $512.86 | $588.84 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,202.26
| Professional | | $645.65 | $758.58 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $1,258.93
| Professional | | $478.63 | $660.69 | $1,258.93 |