- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.59 / $723.68 / $856.99
| Professional | | $529.59 | $723.68 | $856.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.64 / $701.23 / $1,096.30
| Professional | | $506.64 | $701.23 | $1,096.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.45 / $892.10 / $1,186.47
| Professional | | $730.45 | $892.10 | $1,186.47 |
- 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
- $497.96 / $822.42 / $1,243.64
| Professional | | $497.96 | $822.42 | $1,243.64 |