- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,288.25
| Professional | | $575.44 | $724.44 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $1,288.25
| Professional | | $676.08 | $891.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $3,162.28
| Facility | | $588.84 | $588.84 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $891.25 / $1,698.24
| Professional | | $512.86 | $891.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,265.80 / $9,549.93
| Facility | | $1,047.13 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $812.83 / $1,479.11
| Professional | | $588.84 | $812.83 | $1,479.11 |