- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.01 / $875.92 / $973.62
| Professional | | $685.01 | $875.92 | $973.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.74 / $972.64 / $1,534.45
| Professional | | $826.74 | $972.64 | $1,534.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.31 / $1,054.25 / $1,903.31
| Professional | | $868.31 | $1,054.25 | $1,903.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.87 / $1,178.07 / $2,032.99
| Professional | | $720.87 | $1,178.07 | $2,032.99 |