- 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
- $530.85 / $821.98 / $1,286.78
| Professional | | $530.85 | $821.98 | $1,286.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.85 / $664.04 / $1,490.56
| Professional | | $546.85 | $664.04 | $1,490.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.05 / $979.59 / $1,431.17
| Professional | | $708.05 | $979.59 | $1,431.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,628.00 / $7,350.00
| Facility | | $2,569.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.53 / $863.06 / $1,403.50
| Professional | | $532.53 | $863.06 | $1,403.50 |