- 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
- $507.88 / $703.82 / $814.36
| Professional | | $507.88 | $703.82 | $814.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.22 / $685.42 / $1,054.70
| Professional | | $495.22 | $685.42 | $1,054.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.72 / $871.18 / $1,140.11
| Professional | | $677.72 | $871.18 | $1,140.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.32 / $790.29 / $1,196.41
| Professional | | $453.32 | $790.29 | $1,196.41 |