- 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
- $676.08 / $776.25 / $2,041.74
| Professional | | $676.08 | $776.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $776.25 / $1,288.25
| Professional | | $691.83 | $776.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,584.89
| Professional | | $758.58 | $1,023.29 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $891.25 / $1,698.24
| Professional | | $575.44 | $891.25 | $1,698.24 |