- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,127.04 / $3,243.94 / $3,955.04
| Facility | | $2,127.04 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.31 / $932.07 / $1,134.74
| Professional | | $832.31 | $932.07 | $1,134.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.37 / $1,071.02 / $1,775.50
| Professional | | $910.37 | $1,071.02 | $1,775.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.14 / $1,258.83 / $2,144.27
| Professional | | $973.14 | $1,258.83 | $2,144.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.42 / $1,358.55 / $2,290.52
| Professional | | $864.42 | $1,358.55 | $2,290.52 |