- 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
- $615.57 / $854.15 / $990.30
| Professional | | $615.57 | $854.15 | $990.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.66 / $810.61 / $1,283.08
| Professional | | $585.66 | $810.61 | $1,283.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.39 / $1,344.44 / $1,385.16
| Professional | | $844.39 | $1,344.44 | $1,385.16 |
- 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
- $613.63 / $972.40 / $1,455.52
| Professional | | $613.63 | $972.40 | $1,455.52 |