- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $6,798.54
| Facility | | $2,090.73 | $3,706.14 | $6,798.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.37 / $835.73 / $1,216.39
| Professional | | $734.37 | $835.73 | $1,216.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.29 / $994.18 / $1,548.54
| Professional | | $718.29 | $994.18 | $1,548.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.59 / $1,283.80 / $1,675.76
| Professional | | $1,035.59 | $1,283.80 | $1,675.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.35 / $1,055.34 / $1,756.63
| Professional | | $671.35 | $1,055.34 | $1,756.63 |