- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.77 / $1,395.28 / $1,730.36
| Professional | | $656.77 | $1,395.28 | $1,730.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.20 / $646.65 / $646.65
| Professional | | $467.20 | $646.65 | $646.65 |
- 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
- $550.21 / $961.63 / $1,688.74
| Professional | | $550.21 | $961.63 | $1,688.74 |