- 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 / $660.69 / $1,949.84
| Professional | | $436.52 | $660.69 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $660.69 / $1,047.13
| Professional | | $446.68 | $660.69 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $831.76 / $1,412.54
| Professional | | $251.19 | $831.76 | $1,412.54 |
- 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
- $489.78 / $741.31 / $1,202.26
| Professional | | $489.78 | $741.31 | $1,202.26 |