- 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
- $455.46 / $623.17 / $1,011.20
| Professional | | $455.46 | $623.17 | $1,011.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.36 / $687.22 / $1,260.83
| Professional | | $523.36 | $687.22 | $1,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.72 / $996.59 / $1,382.80
| Professional | | $683.72 | $996.59 | $1,382.80 |
- 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
- $570.04 / $968.94 / $1,430.27
| Professional | | $570.04 | $968.94 | $1,430.27 |