- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.71 / $678.33 / $836.51
| Professional | | $485.71 | $678.33 | $836.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.47 / $638.71 / $1,021.75
| Professional | | $461.47 | $638.71 | $1,021.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.32 / $1,089.30 / $1,434.36
| Professional | | $665.32 | $1,089.30 | $1,434.36 |
- 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
- $485.53 / $856.24 / $1,169.53
| Professional | | $485.53 | $856.24 | $1,169.53 |