- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,023.29 / $2,344.23
| Professional | | $741.31 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,412.54
| Professional | | $602.56 | $812.83 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $977.24 / $1,621.81
| Professional | | $181.97 | $977.24 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $977.24 / $1,513.56
| Professional | | $691.83 | $977.24 | $1,513.56 |