- 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
- $731.62 / $964.94 / $1,039.61
| Professional | | $731.62 | $964.94 | $1,039.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.08 / $1,069.51 / $1,634.56
| Professional | | $909.08 | $1,069.51 | $1,634.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.24 / $1,273.22 / $2,101.21
| Professional | | $967.24 | $1,273.22 | $2,101.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.81 / $1,267.71 / $1,857.31
| Professional | | $843.81 | $1,267.71 | $1,857.31 |