- 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
- $604.69 / $831.88 / $960.70
| Professional | | $604.69 | $831.88 | $960.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.66 / $836.90 / $1,224.73
| Professional | | $604.66 | $836.90 | $1,224.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.77 / $1,069.84 / $1,375.23
| Professional | | $871.77 | $1,069.84 | $1,375.23 |
- 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
- $577.92 / $953.27 / $1,461.66
| Professional | | $577.92 | $953.27 | $1,461.66 |