- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,318.78 / $2,993.72 / $3,955.04
| Facility | | $2,318.78 | $2,993.72 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.34 / $633.60 / $902.19
| Professional | | $517.34 | $633.60 | $902.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.19 / $681.23 / $1,084.27
| Professional | | $492.19 | $681.23 | $1,084.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.62 / $1,005.56 / $1,160.60
| Professional | | $709.62 | $1,005.56 | $1,160.60 |
- 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
- $487.11 / $804.50 / $1,251.80
| Professional | | $487.11 | $804.50 | $1,251.80 |