- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.08 / $879.47 / $1,004.66
| Professional | | $631.08 | $879.47 | $1,004.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.02 / $859.54 / $1,286.76
| Professional | | $621.02 | $859.54 | $1,286.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.35 / $1,124.15 / $1,428.73
| Professional | | $895.35 | $1,124.15 | $1,428.73 |
- 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
- $605.59 / $990.36 / $1,497.51
| Professional | | $605.59 | $990.36 | $1,497.51 |