- 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
- $389.05 / $512.86 / $2,691.53
| Professional | | $389.05 | $512.86 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $407.38 / $691.83
| Professional | | $302.00 | $407.38 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $512.86 / $831.76
| Professional | | $151.36 | $512.86 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,912.51
| Facility | | $2,570.40 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $616.60 / $870.96
| Professional | | $354.81 | $616.60 | $870.96 |