- 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
- $456.80 / $617.79 / $870.29
| Professional | | $456.80 | $617.79 | $870.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.85 / $597.72 / $1,139.95
| Professional | | $431.85 | $597.72 | $1,139.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.63 / $860.87 / $1,051.77
| Professional | | $622.63 | $860.87 | $1,051.77 |
- 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
- $404.76 / $721.93 / $1,125.78
| Professional | | $404.76 | $721.93 | $1,125.78 |