- 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
- $593.87 / $645.32 / $759.32
| Professional | | $593.87 | $645.32 | $759.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.10 / $837.76 / $1,273.69
| Professional | | $712.10 | $837.76 | $1,273.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.55 / $902.35 / $1,642.84
| Professional | | $754.55 | $902.35 | $1,642.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.90 / $886.69 / $1,656.62
| Professional | | $590.90 | $886.69 | $1,656.62 |