- 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
- $583.84 / $815.94 / $949.68
| Professional | | $583.84 | $815.94 | $949.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.74 / $770.58 / $1,211.58
| Professional | | $556.74 | $770.58 | $1,211.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.69 / $1,015.38 / $1,311.25
| Professional | | $802.69 | $1,015.38 | $1,311.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.29 / $896.61 / $1,374.40
| Professional | | $579.29 | $896.61 | $1,374.40 |