- 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
- $582.79 / $777.79 / $944.26
| Professional | | $582.79 | $777.79 | $944.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.41 / $767.36 / $1,223.97
| Professional | | $554.41 | $767.36 | $1,223.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.34 / $957.70 / $1,303.83
| Professional | | $661.34 | $957.70 | $1,303.83 |
- 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
- $456.15 / $892.77 / $1,388.45
| Professional | | $456.15 | $892.77 | $1,388.45 |