- 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
- $706.91 / $988.98 / $1,157.55
| Professional | | $706.91 | $988.98 | $1,157.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.61 / $929.57 / $1,475.21
| Professional | | $671.61 | $929.57 | $1,475.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.30 / $1,477.73 / $1,592.71
| Professional | | $968.30 | $1,477.73 | $1,592.71 |
- 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
- $707.87 / $1,125.82 / $1,673.46
| Professional | | $707.87 | $1,125.82 | $1,673.46 |