- 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
- $714.40 / $928.88 / $1,128.66
| Professional | | $714.40 | $928.88 | $1,128.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.98 / $939.76 / $1,307.48
| Professional | | $678.98 | $939.76 | $1,307.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.36 / $1,158.17 / $1,607.45
| Professional | | $962.36 | $1,158.17 | $1,607.45 |
- 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
- $711.82 / $1,097.83 / $1,602.27
| Professional | | $711.82 | $1,097.83 | $1,602.27 |