- 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
- $747.53 / $955.06 / $962.75
| Professional | | $747.53 | $955.06 | $962.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.72 / $1,058.49 / $1,670.39
| Professional | | $899.72 | $1,058.49 | $1,670.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.95 / $1,260.10 / $2,080.40
| Professional | | $957.95 | $1,260.10 | $2,080.40 |
- 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
- $783.86 / $1,285.29 / $1,877.42
| Professional | | $783.86 | $1,285.29 | $1,877.42 |