- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,715.35 / $3,981.07
| Facility | | $2,089.30 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $338.84 / $1,479.11
| Professional | | $245.47 | $338.84 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $257.04 / $426.58
| Professional | | $190.55 | $257.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $346.74 / $524.81
| Professional | | $151.36 | $346.74 | $524.81 |
- 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
- $223.87 / $346.74 / $478.63
| Professional | | $223.87 | $346.74 | $478.63 |