- 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
- $580.47 / $813.77 / $936.12
| Professional | | $580.47 | $813.77 | $936.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.62 / $773.18 / $1,196.50
| Professional | | $558.62 | $773.18 | $1,196.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.41 / $1,265.22 / $1,324.85
| Professional | | $805.41 | $1,265.22 | $1,324.85 |
- 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
- $585.57 / $904.15 / $1,357.28
| Professional | | $585.57 | $904.15 | $1,357.28 |