- 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
- $640.83 / $867.18 / $953.54
| Professional | | $640.83 | $867.18 | $953.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.42 / $843.50 / $1,329.41
| Professional | | $609.42 | $843.50 | $1,329.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.65 / $1,067.33 / $1,435.93
| Professional | | $878.65 | $1,067.33 | $1,435.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.16 / $932.78 / $1,508.05
| Professional | | $630.16 | $932.78 | $1,508.05 |