- 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
- $640.46 / $901.62 / $1,084.83
| Professional | | $640.46 | $901.62 | $1,084.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.82 / $1,019.82 / $1,509.32
| Professional | | $736.82 | $1,019.82 | $1,509.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.31 / $1,194.43 / $1,710.41
| Professional | | $1,062.31 | $1,194.43 | $1,710.41 |
- 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
- $680.08 / $1,185.59 / $1,781.47
| Professional | | $680.08 | $1,185.59 | $1,781.47 |