- 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
- $332.97 / $575.07 / $873.32
| Professional | | $332.97 | $575.07 | $873.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.54 / $720.64 / $1,225.17
| Professional | | $461.54 | $720.64 | $1,225.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.13 / $873.33 / $1,388.85
| Professional | | $394.13 | $873.33 | $1,388.85 |
- 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
- $562.02 / $819.77 / $1,389.80
| Professional | | $562.02 | $819.77 | $1,389.80 |