- 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
- $398.11 / $489.78 / $1,148.15
| Professional | | $398.11 | $489.78 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $389.05 / $691.83
| Professional | | $295.12 | $389.05 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $457.09 / $812.83
| Professional | | $323.59 | $457.09 | $812.83 |
- 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
- $295.12 / $446.68 / $691.83
| Professional | | $295.12 | $446.68 | $691.83 |