- 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
- $690.43 / $961.79 / $1,122.65
| Professional | | $690.43 | $961.79 | $1,122.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.85 / $913.28 / $1,431.72
| Professional | | $659.85 | $913.28 | $1,431.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.33 / $1,450.82 / $1,556.82
| Professional | | $951.33 | $1,450.82 | $1,556.82 |
- 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
- $696.41 / $1,072.77 / $1,624.11
| Professional | | $696.41 | $1,072.77 | $1,624.11 |