- 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
- $588.42 / $753.94 / $811.55
| Professional | | $588.42 | $753.94 | $811.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.46 / $838.19 / $1,311.31
| Professional | | $712.46 | $838.19 | $1,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.11 / $997.85 / $1,649.63
| Professional | | $757.11 | $997.85 | $1,649.63 |
- 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
- $621.10 / $877.44 / $1,475.69
| Professional | | $621.10 | $877.44 | $1,475.69 |