- 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
- $610.48 / $799.75 / $994.27
| Professional | | $610.48 | $799.75 | $994.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.98 / $804.12 / $1,267.97
| Professional | | $580.98 | $804.12 | $1,267.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.62 / $1,023.46 / $1,369.92
| Professional | | $837.62 | $1,023.46 | $1,369.92 |
- 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
- $605.22 / $870.69 / $1,438.36
| Professional | | $605.22 | $870.69 | $1,438.36 |