- 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
- $520.65 / $727.82 / $837.82
| Professional | | $520.65 | $727.82 | $837.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.94 / $690.58 / $1,077.70
| Professional | | $498.94 | $690.58 | $1,077.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.35 / $898.37 / $1,168.07
| Professional | | $719.35 | $898.37 | $1,168.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.04 / $734.78 / $1,222.53
| Professional | | $516.04 | $734.78 | $1,222.53 |