- 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
- $600.25 / $681.39 / $848.54
| Professional | | $600.25 | $681.39 | $848.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.32 / $832.14 / $1,346.68
| Professional | | $707.32 | $832.14 | $1,346.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.12 / $1,158.92 / $1,645.22
| Professional | | $901.12 | $1,158.92 | $1,645.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.55 / $939.12 / $1,508.27
| Professional | | $620.55 | $939.12 | $1,508.27 |