- 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
- $569.04 / $640.82 / $935.90
| Professional | | $569.04 | $640.82 | $935.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.72 / $756.70 / $1,193.31
| Professional | | $546.72 | $756.70 | $1,193.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.22 / $996.74 / $1,290.24
| Professional | | $788.22 | $996.74 | $1,290.24 |
- 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
- $513.01 / $785.61 / $1,290.78
| Professional | | $513.01 | $785.61 | $1,290.78 |