- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,890.45 / $6,456.54
| Facility | | $2,089.30 | $3,890.45 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $794.33 / $1,905.46
| Professional | | $512.86 | $794.33 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $645.65 / $1,122.02
| Professional | | $549.54 | $645.65 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $1,258.93
| Professional | | $676.08 | $870.96 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $724.44 / $1,318.26
| Professional | | $501.19 | $724.44 | $1,318.26 |