- 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
- $683.88 / $772.32 / $1,110.86
| Professional | | $683.88 | $772.32 | $1,110.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.84 / $911.89 / $1,439.06
| Professional | | $658.84 | $911.89 | $1,439.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,199.67 / $1,552.59
| Professional | | $949.88 | $1,199.67 | $1,552.59 |
- 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
- $651.62 / $851.60 / $1,632.43
| Professional | | $651.62 | $851.60 | $1,632.43 |