- 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
- $338.84 / $544.66 / $826.25
| Professional | | $338.84 | $544.66 | $826.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.82 / $630.04 / $1,012.13
| Professional | | $416.82 | $630.04 | $1,012.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.59 / $748.91 / $1,129.97
| Professional | | $528.59 | $748.91 | $1,129.97 |
- 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
- $451.27 / $786.71 / $1,217.30
| Professional | | $451.27 | $786.71 | $1,217.30 |