- 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
- $416.87 / $588.84 / $1,174.90
| Professional | | $416.87 | $588.84 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $457.09 / $794.33
| Professional | | $346.74 | $457.09 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $537.03 / $912.01
| Professional | | $181.97 | $537.03 | $912.01 |
- 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
- $389.05 / $562.34 / $912.01
| Professional | | $389.05 | $562.34 | $912.01 |