- 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
- $263.03 / $562.34 / $912.01
| Professional | | $263.03 | $562.34 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $457.09 / $758.58
| Professional | | $239.88 | $457.09 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $549.54 / $1,230.27
| Professional | | $223.87 | $549.54 | $1,230.27 |
- 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
- $281.84 / $512.86 / $1,548.82
| Professional | | $281.84 | $512.86 | $1,548.82 |