- 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
- $272.01 / $614.99 / $1,071.58
| Professional | | $272.01 | $614.99 | $1,071.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.22 / $805.56 / $1,462.62
| Professional | | $492.22 | $805.56 | $1,462.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.63 / $766.26 / $1,920.58
| Professional | | $256.63 | $766.26 | $1,920.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.51 / $1,331.28 / $2,070.19
| Professional | | $659.51 | $1,331.28 | $2,070.19 |