- 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
- $495.31 / $768.76 / $856.84
| Professional | | $495.31 | $768.76 | $856.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.87 / $729.24 / $1,141.43
| Professional | | $526.87 | $729.24 | $1,141.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.63 / $901.04 / $1,235.08
| Professional | | $759.63 | $901.04 | $1,235.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.79 / $727.71 / $1,294.81
| Professional | | $531.79 | $727.71 | $1,294.81 |