- 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
- $677.49 / $936.46 / $1,111.92
| Professional | | $677.49 | $936.46 | $1,111.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.38 / $889.10 / $1,397.46
| Professional | | $642.38 | $889.10 | $1,397.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.15 / $1,154.70 / $1,537.17
| Professional | | $926.15 | $1,154.70 | $1,537.17 |
- 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
- $663.36 / $947.10 / $1,585.24
| Professional | | $663.36 | $947.10 | $1,585.24 |