- 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
- $761.26 / $882.56 / $902.06
| Professional | | $761.26 | $882.56 | $902.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.81 / $963.30 / $1,502.68
| Professional | | $818.81 | $963.30 | $1,502.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.58 / $964.57 / $1,721.30
| Professional | | $651.58 | $964.57 | $1,721.30 |
- 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
- $559.23 / $788.82 / $1,187.34
| Professional | | $559.23 | $788.82 | $1,187.34 |