- 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
- $489.78 / $549.54 / $1,513.56
| Professional | | $489.78 | $549.54 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $562.34 / $912.01
| Professional | | $501.19 | $562.34 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $794.33 / $1,148.15
| Professional | | $616.60 | $794.33 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,413.10 / $13,489.63
| Facility | | $3,715.35 | $7,413.10 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $645.65 / $1,202.26
| Professional | | $436.52 | $645.65 | $1,202.26 |