- 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
- $776.25 / $933.25 / $2,041.74
| Professional | | $776.25 | $933.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $1,348.96
| Professional | | $676.08 | $794.33 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,096.48 / $1,778.28
| Professional | | $707.95 | $1,096.48 | $1,778.28 |
- 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
- $575.44 / $851.14 / $1,258.93
| Professional | | $575.44 | $851.14 | $1,258.93 |