- 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
- $648.45 / $888.14 / $1,029.65
| Professional | | $648.45 | $888.14 | $1,029.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.59 / $858.94 / $1,283.85
| Professional | | $620.59 | $858.94 | $1,283.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.72 / $1,175.96 / $1,422.56
| Professional | | $894.72 | $1,175.96 | $1,422.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.29 / $986.07 / $1,506.57
| Professional | | $618.29 | $986.07 | $1,506.57 |