- 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
- $338.84 / $426.58 / $1,096.48
| Professional | | $338.84 | $426.58 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $478.63 / $758.58
| Professional | | $380.19 | $478.63 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $616.60 / $831.76
| Professional | | $436.52 | $616.60 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $478.63 / $851.14
| Professional | | $331.13 | $478.63 | $851.14 |