- 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
- $640.58 / $863.08 / $1,061.70
| Professional | | $640.58 | $863.08 | $1,061.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.77 / $839.82 / $1,370.06
| Professional | | $606.77 | $839.82 | $1,370.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.12 / $1,059.83 / $1,453.12
| Professional | | $613.12 | $1,059.83 | $1,453.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,052.00 / $6,004.05
| Facility | | $1,812.00 | $4,052.00 | $6,004.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.44 / $1,007.25 / $1,552.52
| Professional | | $442.44 | $1,007.25 | $1,552.52 |