- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,819.70 / $2,511.89
| Facility | | $1,023.29 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $870.96 / $1,258.93
| Professional | | $776.25 | $870.96 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,230.27 / $1,445.44
| Professional | | $691.83 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,677.35 / $9,332.54
| Facility | | $2,187.76 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,548.82
| Professional | | $758.58 | $977.24 | $1,548.82 |