- 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
- $553.96 / $677.12 / $871.20
| Professional | | $553.96 | $677.12 | $871.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.74 / $912.61 / $1,262.78
| Professional | | $640.74 | $912.61 | $1,262.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.03 / $987.04 / $1,790.22
| Professional | | $759.03 | $987.04 | $1,790.22 |
- 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
- $663.38 / $969.32 / $1,632.12
| Professional | | $663.38 | $969.32 | $1,632.12 |