- 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
- $520.01 / $588.74 / $845.33
| Professional | | $520.01 | $588.74 | $845.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.28 / $696.58 / $1,088.92
| Professional | | $503.28 | $696.58 | $1,088.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.60 / $910.75 / $1,178.60
| Professional | | $725.60 | $910.75 | $1,178.60 |
- 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
- $509.49 / $816.97 / $1,235.26
| Professional | | $509.49 | $816.97 | $1,235.26 |