- 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
- $363.08 / $501.19 / $1,288.25
| Professional | | $363.08 | $501.19 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $501.19 / $812.83
| Professional | | $371.54 | $501.19 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $645.65 / $977.24
| Professional | | $151.36 | $645.65 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $602.56 / $1,023.29
| Professional | | $371.54 | $602.56 | $1,023.29 |