- 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
- $416.87 / $645.65 / $1,380.38
| Professional | | $416.87 | $645.65 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $588.84 / $1,071.52
| Professional | | $426.58 | $588.84 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $776.25 / $1,230.27
| Professional | | $251.19 | $776.25 | $1,230.27 |
- 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
- $426.58 / $660.69 / $1,096.48
| Professional | | $426.58 | $660.69 | $1,096.48 |