- 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
- $518.94 / $710.07 / $842.71
| Professional | | $518.94 | $710.07 | $842.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.22 / $688.19 / $1,073.11
| Professional | | $497.22 | $688.19 | $1,073.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.86 / $875.95 / $1,161.65
| Professional | | $716.86 | $875.95 | $1,161.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.31 / $796.69 / $1,217.31
| Professional | | $502.31 | $796.69 | $1,217.31 |