- 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
- $501.93 / $698.63 / $814.23
| Professional | | $501.93 | $698.63 | $814.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.40 / $660.76 / $1,045.56
| Professional | | $477.40 | $660.76 | $1,045.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.29 / $874.70 / $1,123.76
| Professional | | $688.29 | $874.70 | $1,123.76 |
- 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
- $485.58 / $769.02 / $1,186.06
| Professional | | $485.58 | $769.02 | $1,186.06 |