- 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
- $639.61 / $920.62 / $1,132.22
| Professional | | $639.61 | $920.62 | $1,132.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.25 / $833.56 / $1,638.24
| Professional | | $602.25 | $833.56 | $1,638.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.28 / $1,259.60 / $1,473.93
| Professional | | $868.28 | $1,259.60 | $1,473.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.74 / $1,033.64 / $1,566.44
| Professional | | $644.74 | $1,033.64 | $1,566.44 |