- 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
- $465.73 / $624.71 / $725.22
| Professional | | $465.73 | $624.71 | $725.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.10 / $730.35 / $1,040.31
| Professional | | $564.10 | $730.35 | $1,040.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.69 / $814.34 / $1,444.36
| Professional | | $679.69 | $814.34 | $1,444.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.79 / $893.30 / $1,310.36
| Professional | | $564.79 | $893.30 | $1,310.36 |