- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $2,454.71
| Facility | | $1,174.90 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,445.44
| Professional | | $912.01 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,584.89 / $1,995.26
| Professional | | $891.25 | $1,584.89 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $9,549.93 / $15,488.17
| Facility | | $3,715.35 | $9,549.93 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $1,949.84
| Professional | | $870.96 | $1,258.93 | $1,949.84 |