- 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
- $498.22 / $676.00 / $862.88
| Professional | | $498.22 | $676.00 | $862.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.29 / $641.24 / $1,089.95
| Professional | | $463.29 | $641.24 | $1,089.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.97 / $940.88 / $1,152.53
| Professional | | $667.97 | $940.88 | $1,152.53 |
- 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
- $491.94 / $814.68 / $1,235.54
| Professional | | $491.94 | $814.68 | $1,235.54 |