- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,943.28 / $8,709.64
| Facility | | $2,398.83 | $7,943.28 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,230.27 / $2,238.72
| Professional | | $676.08 | $1,230.27 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $741.31 / $1,258.93
| Professional | | $660.69 | $741.31 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,513.56
| Professional | | $831.76 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $954.99 / $1,621.81
| Professional | | $660.69 | $954.99 | $1,621.81 |