- 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
- $671.27 / $884.23 / $936.51
| Professional | | $671.27 | $884.23 | $936.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.43 / $980.50 / $1,484.25
| Professional | | $833.43 | $980.50 | $1,484.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.65 / $1,167.27 / $1,928.68
| Professional | | $886.65 | $1,167.27 | $1,928.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.46 / $1,019.87 / $1,674.38
| Professional | | $758.46 | $1,019.87 | $1,674.38 |