- 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
- $660.65 / $769.20 / $1,054.27
| Professional | | $660.65 | $769.20 | $1,054.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.11 / $908.11 / $1,334.25
| Professional | | $656.11 | $908.11 | $1,334.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.95 / $1,172.72 / $1,500.83
| Professional | | $945.95 | $1,172.72 | $1,500.83 |
- 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
- $625.52 / $1,040.33 / $1,583.99
| Professional | | $625.52 | $1,040.33 | $1,583.99 |