- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,706.14 / $8,677.33
| Facility | | $2,424.15 | $3,706.14 | $8,677.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.46 / $769.07 / $1,111.23
| Professional | | $662.46 | $769.07 | $1,111.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.69 / $879.85 / $1,403.47
| Professional | | $635.69 | $879.85 | $1,403.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.51 / $1,206.48 / $1,527.77
| Professional | | $916.51 | $1,206.48 | $1,527.77 |
- 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
- $674.95 / $1,071.98 / $1,592.07
| Professional | | $674.95 | $1,071.98 | $1,592.07 |