- 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
- $549.54 / $676.08 / $1,737.80
| Professional | | $549.54 | $676.08 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $588.84 / $977.24
| Professional | | $446.68 | $588.84 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $724.44 / $1,174.90
| Professional | | $89.13 | $724.44 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $11,220.18
| Facility | | $2,818.38 | $5,128.61 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $1,096.48
| Professional | | $512.86 | $758.58 | $1,096.48 |