- 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
- $523.97 / $797.72 / $889.12
| Professional | | $523.97 | $797.72 | $889.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.73 / $769.18 / $1,220.14
| Professional | | $555.73 | $769.18 | $1,220.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.23 / $979.80 / $1,306.43
| Professional | | $801.23 | $979.80 | $1,306.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,164.00 / $9,622.00
| Facility | | $2,838.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.52 / $905.58 / $1,384.11
| Professional | | $564.52 | $905.58 | $1,384.11 |