- 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
- $467.74 / $616.60 / $1,412.54
| Professional | | $467.74 | $616.60 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $524.81 / $1,047.13
| Professional | | $446.68 | $524.81 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $1,096.48
| Professional | | $630.96 | $870.96 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $741.31 / $1,148.15
| Professional | | $467.74 | $741.31 | $1,148.15 |