- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.74 / $942.32 / $1,101.71
| Professional | | $674.74 | $942.32 | $1,101.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.08 / $887.30 / $1,403.31
| Professional | | $641.08 | $887.30 | $1,403.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.27 / $1,176.90 / $1,515.51
| Professional | | $924.27 | $1,176.90 | $1,515.51 |
- 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
- $669.54 / $1,050.50 / $1,591.88
| Professional | | $669.54 | $1,050.50 | $1,591.88 |