- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.48 / $979.54 / $1,140.22
| Professional | | $700.48 | $979.54 | $1,140.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.11 / $927.49 / $1,451.78
| Professional | | $670.11 | $927.49 | $1,451.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.14 / $1,214.58 / $1,571.80
| Professional | | $966.14 | $1,214.58 | $1,571.80 |
- 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
- $694.40 / $1,089.51 / $1,646.88
| Professional | | $694.40 | $1,089.51 | $1,646.88 |