- 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
- $586.26 / $815.91 / $935.38
| Professional | | $586.26 | $815.91 | $935.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.20 / $814.12 / $1,207.74
| Professional | | $588.20 | $814.12 | $1,207.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.04 / $1,064.71 / $1,340.17
| Professional | | $848.04 | $1,064.71 | $1,340.17 |
- 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
- $574.78 / $928.97 / $1,421.78
| Professional | | $574.78 | $928.97 | $1,421.78 |