- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.23 / $460.99 / $491.17
| Professional | | $218.23 | $460.99 | $491.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,521.69 / $3,482.54 / $3,962.89
| Facility | | $2,521.69 | $3,482.54 | $3,962.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.08 / $637.54 / $982.32
| Professional | | $473.08 | $637.54 | $982.32 |