- 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
- $269.15 / $436.52 / $1,202.26
| Professional | | $269.15 | $436.52 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $389.05 / $707.95
| Professional | | $263.03 | $389.05 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $512.86 / $933.25
| Professional | | $346.74 | $512.86 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $851.14
| Professional | | $302.00 | $457.09 | $851.14 |