- 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
- $483.79 / $654.04 / $1,021.85
| Professional | | $483.79 | $654.04 | $1,021.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.04 / $620.12 / $1,325.04
| Professional | | $448.04 | $620.12 | $1,325.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.97 / $937.04 / $1,098.76
| Professional | | $645.97 | $937.04 | $1,098.76 |
- 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
- $465.71 / $740.27 / $1,140.86
| Professional | | $465.71 | $740.27 | $1,140.86 |