- 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
- $646.36 / $885.73 / $1,036.13
| Professional | | $646.36 | $885.73 | $1,036.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.58 / $850.62 / $1,341.45
| Professional | | $614.58 | $850.62 | $1,341.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.07 / $1,090.59 / $1,449.46
| Professional | | $886.07 | $1,090.59 | $1,449.46 |
- 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
- $626.17 / $1,004.72 / $1,521.72
| Professional | | $626.17 | $1,004.72 | $1,521.72 |