- 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
- $588.84 / $831.76 / $1,621.81
| Professional | | $588.84 | $831.76 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $1,230.27
| Professional | | $630.96 | $707.95 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,445.44
| Professional | | $758.58 | $954.99 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $15,135.61
| Facility | | $3,235.94 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $812.83 / $1,621.81
| Professional | | $549.54 | $812.83 | $1,621.81 |