- 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
- $239.88 / $524.81 / $1,348.96
| Professional | | $239.88 | $524.81 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $239.88 / $851.14
| Professional | | $177.83 | $239.88 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $389.05 / $1,023.29
| Professional | | $181.97 | $389.05 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $512.86 / $812.83
| Professional | | $346.74 | $512.86 | $812.83 |