- 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
- $240.47 / $552.73 / $1,595.65
| Professional | | $240.47 | $552.73 | $1,595.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.48 / $847.06 / $2,221.42
| Professional | | $507.48 | $847.06 | $2,221.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.18 / $975.79 / $2,907.64
| Professional | | $324.18 | $975.79 | $2,907.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.15 / $1,588.03 / $2,939.03
| Professional | | $1,398.15 | $1,588.03 | $2,939.03 |