- 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
- $691.83 / $976.50 / $1,097.67
| Professional | | $691.83 | $976.50 | $1,097.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.52 / $957.12 / $1,433.11
| Professional | | $691.52 | $957.12 | $1,433.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.00 / $1,264.58 / $1,593.10
| Professional | | $997.00 | $1,264.58 | $1,593.10 |
- 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
- $692.38 / $1,104.28 / $1,671.70
| Professional | | $692.38 | $1,104.28 | $1,671.70 |