- 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
- $512.14 / $719.86 / $828.08
| Professional | | $512.14 | $719.86 | $828.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.14 / $682.54 / $1,058.49
| Professional | | $493.14 | $682.54 | $1,058.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.98 / $1,136.93 / $1,192.44
| Professional | | $710.98 | $1,136.93 | $1,192.44 |
- 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
- $509.67 / $837.40 / $1,200.73
| Professional | | $509.67 | $837.40 | $1,200.73 |