- 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
- $492.57 / $675.23 / $790.83
| Professional | | $492.57 | $675.23 | $790.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.65 / $661.10 / $1,022.83
| Professional | | $477.65 | $661.10 | $1,022.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.65 / $834.25 / $1,108.58
| Professional | | $688.65 | $834.25 | $1,108.58 |
- 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
- $465.27 / $768.44 / $1,160.27
| Professional | | $465.27 | $768.44 | $1,160.27 |