- 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
- $703.26 / $881.72 / $973.72
| Professional | | $703.26 | $881.72 | $973.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.25 / $976.77 / $1,576.54
| Professional | | $830.25 | $976.77 | $1,576.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.11 / $1,056.31 / $1,933.26
| Professional | | $880.11 | $1,056.31 | $1,933.26 |
- 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
- $730.28 / $1,183.61 / $1,770.28
| Professional | | $730.28 | $1,183.61 | $1,770.28 |