- 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
- $589.44 / $823.74 / $958.45
| Professional | | $589.44 | $823.74 | $958.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.37 / $778.37 / $1,223.58
| Professional | | $562.37 | $778.37 | $1,223.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.80 / $1,026.84 / $1,322.72
| Professional | | $810.80 | $1,026.84 | $1,322.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.37 / $916.86 / $1,388.02
| Professional | | $571.37 | $916.86 | $1,388.02 |