- 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
- $302.00 / $389.05 / $1,047.13
| Professional | | $302.00 | $389.05 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $389.05 / $630.96
| Professional | | $338.84 | $389.05 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $724.44
| Professional | | $407.38 | $489.78 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,912.51
| Facility | | $2,570.40 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $398.11 / $851.14
| Professional | | $269.15 | $398.11 | $851.14 |