- 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
- $551.07 / $769.24 / $875.75
| Professional | | $551.07 | $769.24 | $875.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.35 / $728.52 / $1,140.77
| Professional | | $526.35 | $728.52 | $1,140.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.87 / $948.94 / $1,235.09
| Professional | | $758.87 | $948.94 | $1,235.09 |
- 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
- $545.66 / $822.95 / $1,319.82
| Professional | | $545.66 | $822.95 | $1,319.82 |