- 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
- $565.97 / $789.56 / $913.33
| Professional | | $565.97 | $789.56 | $913.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.20 / $747.68 / $1,172.24
| Professional | | $540.20 | $747.68 | $1,172.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.83 / $1,170.08 / $1,274.32
| Professional | | $778.83 | $1,170.08 | $1,274.32 |
- 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
- $560.78 / $897.25 / $1,356.25
| Professional | | $560.78 | $897.25 | $1,356.25 |