- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.71 / $992.65 / $1,205.55
| Professional | | $733.71 | $992.65 | $1,205.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.77 / $938.09 / $1,602.58
| Professional | | $677.77 | $938.09 | $1,602.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.18 / $1,329.09 / $1,646.03
| Professional | | $977.18 | $1,329.09 | $1,646.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.83 / $1,140.96 / $1,762.16
| Professional | | $690.83 | $1,140.96 | $1,762.16 |