- 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
- $609.52 / $861.43 / $987.99
| Professional | | $609.52 | $861.43 | $987.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.64 / $817.49 / $1,267.65
| Professional | | $590.64 | $817.49 | $1,267.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.56 / $1,094.44 / $1,362.84
| Professional | | $851.56 | $1,094.44 | $1,362.84 |
- 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
- $602.08 / $944.66 / $1,438.01
| Professional | | $602.08 | $944.66 | $1,438.01 |