- 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
- $528.54 / $735.63 / $858.59
| Professional | | $528.54 | $735.63 | $858.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.12 / $700.51 / $1,092.88
| Professional | | $506.12 | $700.51 | $1,092.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.70 / $907.43 / $1,185.76
| Professional | | $729.70 | $907.43 | $1,185.76 |
- 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
- $523.86 / $821.93 / $1,239.75
| Professional | | $523.86 | $821.93 | $1,239.75 |