- 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
- $594.07 / $828.44 / $963.36
| Professional | | $594.07 | $828.44 | $963.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.60 / $785.60 / $1,227.58
| Professional | | $567.60 | $785.60 | $1,227.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.34 / $1,026.91 / $1,331.78
| Professional | | $818.34 | $1,026.91 | $1,331.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,164.00 / $9,622.00
| Facility | | $2,838.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.36 / $833.50 / $1,392.55
| Professional | | $588.36 | $833.50 | $1,392.55 |