- 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
- $436.52 / $616.60 / $1,174.90
| Professional | | $436.52 | $616.60 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $776.25
| Professional | | $389.05 | $512.86 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $602.56 / $1,096.48
| Professional | | $363.08 | $602.56 | $1,096.48 |
- 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
- $398.11 / $616.60 / $933.25
| Professional | | $398.11 | $616.60 | $933.25 |