- 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
- $552.95 / $710.22 / $910.54
| Professional | | $552.95 | $710.22 | $910.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.63 / $910.72 / $1,296.79
| Professional | | $673.63 | $910.72 | $1,296.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.58 / $978.58 / $1,796.04
| Professional | | $799.58 | $978.58 | $1,796.04 |
- 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
- $722.08 / $1,114.71 / $1,868.89
| Professional | | $722.08 | $1,114.71 | $1,868.89 |