- 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
- $636.94 / $823.26 / $1,138.57
| Professional | | $636.94 | $823.26 | $1,138.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.34 / $880.74 / $1,487.05
| Professional | | $636.34 | $880.74 | $1,487.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.74 / $1,089.36 / $1,436.64
| Professional | | $880.74 | $1,089.36 | $1,436.64 |
- 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
- $602.96 / $969.76 / $1,646.59
| Professional | | $602.96 | $969.76 | $1,646.59 |