- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.02 / $922.78 / $1,075.04
| Professional | | $661.02 | $922.78 | $1,075.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.29 / $869.60 / $1,374.08
| Professional | | $628.29 | $869.60 | $1,374.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.83 / $1,151.34 / $1,484.28
| Professional | | $905.83 | $1,151.34 | $1,484.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,007.00 / $6,315.00 / $12,945.00
| Facility | | $3,007.00 | $6,315.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.02 / $1,020.90 / $1,558.75
| Professional | | $641.02 | $1,020.90 | $1,558.75 |