- 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
- $580.54 / $670.71 / $926.57
| Professional | | $580.54 | $670.71 | $926.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.41 / $828.25 / $1,176.66
| Professional | | $598.41 | $828.25 | $1,176.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.76 / $1,044.00 / $1,314.97
| Professional | | $862.76 | $1,044.00 | $1,314.97 |
- 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
- $571.30 / $916.89 / $1,392.43
| Professional | | $571.30 | $916.89 | $1,392.43 |