- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.34 / $661.40 / $1,012.56
| Professional | | $434.34 | $661.40 | $1,012.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.70 / $798.29 / $1,357.58
| Professional | | $535.70 | $798.29 | $1,357.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.32 / $925.00 / $1,395.75
| Professional | | $694.32 | $925.00 | $1,395.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.29 / $905.00 / $1,540.01
| Professional | | $548.29 | $905.00 | $1,540.01 |