- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,454.71
| Facility | | $1,023.29 | $1,621.81 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $933.25 / $1,202.26
| Professional | | $812.83 | $933.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,288.25 / $1,584.89
| Professional | | $741.31 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $16,982.44
| Facility | | $2,187.76 | $5,888.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,698.24
| Professional | | $776.25 | $1,047.13 | $1,698.24 |