- 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
- $465.67 / $624.53 / $810.04
| Professional | | $465.67 | $624.53 | $810.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.69 / $808.13 / $1,081.57
| Professional | | $565.69 | $808.13 | $1,081.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.97 / $876.87 / $1,582.41
| Professional | | $640.97 | $876.87 | $1,582.41 |
- 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
- $583.25 / $986.95 / $1,641.50
| Professional | | $583.25 | $986.95 | $1,641.50 |