- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.34 / $678.13 / $908.53
| Professional | | $456.34 | $678.13 | $908.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.04 / $672.34 / $1,291.01
| Professional | | $517.04 | $672.34 | $1,291.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.39 / $924.01 / $1,247.47
| Professional | | $634.39 | $924.01 | $1,247.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.41 / $827.52 / $1,464.50
| Professional | | $485.41 | $827.52 | $1,464.50 |