- 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
- $698.39 / $964.30 / $1,137.65
| Professional | | $698.39 | $964.30 | $1,137.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.03 / $919.07 / $1,449.35
| Professional | | $664.03 | $919.07 | $1,449.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.08 / $1,187.84 / $1,563.49
| Professional | | $762.08 | $1,187.84 | $1,563.49 |
- 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
- $547.00 / $1,083.76 / $1,644.13
| Professional | | $547.00 | $1,083.76 | $1,644.13 |