- 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
- $257.04 / $616.60 / $1,148.15
| Professional | | $257.04 | $616.60 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $616.60 / $1,122.02
| Professional | | $257.04 | $616.60 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,174.90 / $1,174.90
| Facility | | $588.84 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $1,479.11
| Professional | | $295.12 | $588.84 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,398.83 / $5,495.41
| Facility | | $794.33 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $575.44 / $1,148.15
| Professional | | $269.15 | $575.44 | $1,148.15 |