- 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
- $571.62 / $624.35 / $648.82
| Professional | | $571.62 | $624.35 | $648.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.62 / $671.32 / $1,112.24
| Professional | | $570.62 | $671.32 | $1,112.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.59 / $662.95 / $1,185.19
| Professional | | $447.59 | $662.95 | $1,185.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,052.00 / $5,510.00
| Facility | | $1,812.00 | $4,052.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.80 / $570.27 / $889.90
| Professional | | $489.80 | $570.27 | $889.90 |