- 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
- $505.41 / $683.06 / $807.49
| Professional | | $505.41 | $683.06 | $807.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.99 / $671.27 / $1,040.78
| Professional | | $484.99 | $671.27 | $1,040.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.23 / $843.38 / $1,127.08
| Professional | | $699.23 | $843.38 | $1,127.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.03 / $702.96 / $1,180.66
| Professional | | $473.03 | $702.96 | $1,180.66 |