- 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
- $676.87 / $944.86 / $1,100.02
| Professional | | $676.87 | $944.86 | $1,100.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.24 / $890.29 / $1,406.96
| Professional | | $643.24 | $890.29 | $1,406.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.39 / $1,176.14 / $1,520.01
| Professional | | $927.39 | $1,176.14 | $1,520.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.33 / $1,037.97 / $1,596.02
| Professional | | $656.33 | $1,037.97 | $1,596.02 |