- 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
- $229.29 / $548.08 / $1,267.36
| Professional | | $229.29 | $548.08 | $1,267.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.15 / $737.29 / $1,625.91
| Professional | | $441.15 | $737.29 | $1,625.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.62 / $692.13 / $1,969.16
| Professional | | $278.62 | $692.13 | $1,969.16 |
- 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
- $902.96 / $1,277.50 / $1,941.75
| Professional | | $902.96 | $1,277.50 | $1,941.75 |