- 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
- $682.09 / $925.63 / $1,120.46
| Professional | | $682.09 | $925.63 | $1,120.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.02 / $866.46 / $1,489.64
| Professional | | $626.02 | $866.46 | $1,489.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.24 / $973.90 / $1,518.82
| Professional | | $830.24 | $973.90 | $1,518.82 |
- 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
- $637.45 / $923.04 / $1,620.91
| Professional | | $637.45 | $923.04 | $1,620.91 |