- 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
- $599.10 / $835.78 / $964.60
| Professional | | $599.10 | $835.78 | $964.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.70 / $791.28 / $1,242.84
| Professional | | $571.70 | $791.28 | $1,242.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.24 / $1,038.01 / $1,341.65
| Professional | | $824.24 | $1,038.01 | $1,341.65 |
- 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
- $579.72 / $790.50 / $1,409.88
| Professional | | $579.72 | $790.50 | $1,409.88 |