- 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
- $446.68 / $645.65 / $1,479.11
| Professional | | $446.68 | $645.65 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $588.84 / $1,071.52
| Professional | | $446.68 | $588.84 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $758.58 / $1,380.38
| Professional | | $457.09 | $758.58 | $1,380.38 |
- 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
- $407.38 / $691.83 / $1,258.93
| Professional | | $407.38 | $691.83 | $1,258.93 |