- 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
- $710.44 / $993.46 / $1,162.35
| Professional | | $710.44 | $993.46 | $1,162.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.04 / $938.46 / $1,487.26
| Professional | | $678.04 | $938.46 | $1,487.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.56 / $1,247.76 / $1,616.84
| Professional | | $977.56 | $1,247.76 | $1,616.84 |
- 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
- $678.58 / $1,120.73 / $1,687.12
| Professional | | $678.58 | $1,120.73 | $1,687.12 |