- 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
- $678.72 / $867.43 / $877.67
| Professional | | $678.72 | $867.43 | $877.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.50 / $961.77 / $1,529.80
| Professional | | $817.50 | $961.77 | $1,529.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.87 / $1,144.96 / $1,889.22
| Professional | | $868.87 | $1,144.96 | $1,889.22 |
- 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
- $724.20 / $1,014.84 / $1,706.46
| Professional | | $724.20 | $1,014.84 | $1,706.46 |