- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $1,819.70
| Professional | | $575.44 | $645.65 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $660.69 / $1,071.52
| Professional | | $562.34 | $660.69 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,148.15 / $1,348.96
| Professional | | $724.44 | $1,148.15 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $891.25 / $1,412.54
| Professional | | $575.44 | $891.25 | $1,412.54 |