- 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
- $257.04 / $575.44 / $1,288.25
| Professional | | $257.04 | $575.44 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $331.13 / $870.96
| Professional | | $229.09 | $331.13 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $794.33 / $1,258.93
| Professional | | $316.23 | $794.33 | $1,258.93 |
- 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
- $457.09 / $724.44 / $1,318.26
| Professional | | $457.09 | $724.44 | $1,318.26 |