- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,650.64 / $3,955.04
| Facility | | $2,090.73 | $3,650.64 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.85 / $715.96 / $820.44
| Professional | | $503.85 | $715.96 | $820.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.40 / $721.66 / $1,060.33
| Professional | | $521.40 | $721.66 | $1,060.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.72 / $888.57 / $1,146.46
| Professional | | $751.72 | $888.57 | $1,146.46 |
- 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
- $469.93 / $794.70 / $1,225.31
| Professional | | $469.93 | $794.70 | $1,225.31 |