- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.01 / $784.10 / $1,227.57
| Professional | | $552.01 | $784.10 | $1,227.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.85 / $788.72 / $1,584.52
| Professional | | $588.85 | $788.72 | $1,584.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.70 / $1,153.89 / $1,640.01
| Professional | | $765.70 | $1,153.89 | $1,640.01 |
- 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
- $706.17 / $1,071.36 / $1,774.26
| Professional | | $706.17 | $1,071.36 | $1,774.26 |