- 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
- $689.84 / $792.53 / $1,123.46
| Professional | | $689.84 | $792.53 | $1,123.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.39 / $915.42 / $1,445.08
| Professional | | $661.39 | $915.42 | $1,445.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.56 / $1,207.52 / $1,559.70
| Professional | | $953.56 | $1,207.52 | $1,559.70 |
- 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
- $673.69 / $1,081.14 / $1,639.29
| Professional | | $673.69 | $1,081.14 | $1,639.29 |