- 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
- $564.79 / $790.31 / $920.62
| Professional | | $564.79 | $790.31 | $920.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.71 / $751.15 / $1,172.83
| Professional | | $542.71 | $751.15 | $1,172.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.45 / $978.76 / $1,268.34
| Professional | | $782.45 | $978.76 | $1,268.34 |
- 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
- $519.67 / $869.51 / $1,330.46
| Professional | | $519.67 | $869.51 | $1,330.46 |