- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $645.65 / $1,737.80
| Professional | | $562.34 | $645.65 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $1,096.48
| Professional | | $575.44 | $645.65 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,348.96
| Professional | | $660.69 | $851.14 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $724.44 / $1,380.38
| Professional | | $457.09 | $724.44 | $1,380.38 |