- 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
- $573.80 / $889.44 / $1,064.43
| Professional | | $573.80 | $889.44 | $1,064.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.91 / $964.10 / $1,372.23
| Professional | | $787.91 | $964.10 | $1,372.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.56 / $1,181.50 / $1,792.76
| Professional | | $694.56 | $1,181.50 | $1,792.76 |
- 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
- $508.23 / $1,075.98 / $1,651.54
| Professional | | $508.23 | $1,075.98 | $1,651.54 |