- 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
- $571.32 / $674.85 / $976.76
| Professional | | $571.32 | $674.85 | $976.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.46 / $799.25 / $1,253.78
| Professional | | $577.46 | $799.25 | $1,253.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.55 / $1,003.08 / $1,353.93
| Professional | | $832.55 | $1,003.08 | $1,353.93 |
- 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
- $568.24 / $926.82 / $1,422.28
| Professional | | $568.24 | $926.82 | $1,422.28 |