- 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
- $647.75 / $709.65 / $747.76
| Professional | | $647.75 | $709.65 | $747.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.37 / $762.79 / $1,275.36
| Professional | | $648.37 | $762.79 | $1,275.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.82 / $751.65 / $1,342.86
| Professional | | $507.82 | $751.65 | $1,342.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.58 / $657.55 / $1,009.61
| Professional | | $457.58 | $657.55 | $1,009.61 |