- 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
- $612.51 / $856.45 / $982.63
| Professional | | $612.51 | $856.45 | $982.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.72 / $805.15 / $1,128.92
| Professional | | $581.72 | $805.15 | $1,128.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.70 / $1,069.83 / $1,377.52
| Professional | | $838.70 | $1,069.83 | $1,377.52 |
- 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
- $574.04 / $954.84 / $1,478.52
| Professional | | $574.04 | $954.84 | $1,478.52 |