- 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
- $602.56 / $676.08 / $1,995.26
| Professional | | $602.56 | $676.08 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $691.83 / $1,202.26
| Professional | | $524.81 | $691.83 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $891.25 / $1,445.44
| Professional | | $151.36 | $891.25 | $1,445.44 |
- 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
- $602.56 / $851.14 / $1,412.54
| Professional | | $602.56 | $851.14 | $1,412.54 |