- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $12,302.69
| Facility | | $3,311.31 | $5,888.44 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,995.26 / $8,912.51
| Facility | | $812.83 | $1,995.26 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $2,754.23
| Professional | | $1,905.46 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $954.99
| Professional | | $478.63 | $616.60 | $954.99 |