- 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
- $625.60 / $846.67 / $1,138.17
| Professional | | $625.60 | $846.67 | $1,138.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.48 / $807.59 / $1,392.85
| Professional | | $583.48 | $807.59 | $1,392.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.01 / $1,221.91 / $1,427.91
| Professional | | $782.01 | $1,221.91 | $1,427.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.52 / $953.74 / $1,506.03
| Professional | | $504.52 | $953.74 | $1,506.03 |