- 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
- $619.78 / $846.97 / $1,008.27
| Professional | | $619.78 | $846.97 | $1,008.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.72 / $816.22 / $1,120.68
| Professional | | $589.72 | $816.22 | $1,120.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.23 / $1,060.22 / $1,388.13
| Professional | | $850.23 | $1,060.22 | $1,388.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.60 / $962.20 / $1,390.47
| Professional | | $582.60 | $962.20 | $1,390.47 |