- 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
- $628.52 / $877.83 / $1,016.61
| Professional | | $628.52 | $877.83 | $1,016.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.14 / $827.87 / $1,306.21
| Professional | | $598.14 | $827.87 | $1,306.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.37 / $1,081.26 / $1,411.29
| Professional | | $862.37 | $1,081.26 | $1,411.29 |
- 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
- $609.54 / $978.26 / $1,507.42
| Professional | | $609.54 | $978.26 | $1,507.42 |