- 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
- $550.42 / $807.59 / $1,089.71
| Professional | | $550.42 | $807.59 | $1,089.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.08 / $885.92 / $1,313.04
| Professional | | $640.08 | $885.92 | $1,313.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.84 / $1,199.51 / $1,504.89
| Professional | | $922.84 | $1,199.51 | $1,504.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.00 / $5,979.00 / $12,680.00
| Facility | | $2,609.00 | $5,979.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.22 / $985.50 / $1,510.83
| Professional | | $650.22 | $985.50 | $1,510.83 |