- 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
- $536.58 / $715.35 / $896.43
| Professional | | $536.58 | $715.35 | $896.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.00 / $887.73 / $1,225.85
| Professional | | $622.00 | $887.73 | $1,225.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.03 / $958.43 / $1,735.89
| Professional | | $737.03 | $958.43 | $1,735.89 |
- 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
- $639.08 / $1,028.07 / $1,859.64
| Professional | | $639.08 | $1,028.07 | $1,859.64 |