- 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
- $553.12 / $755.13 / $864.13
| Professional | | $553.12 | $755.13 | $864.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.20 / $765.67 / $1,080.50
| Professional | | $553.20 | $765.67 | $1,080.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.57 / $976.87 / $1,254.08
| Professional | | $797.57 | $976.87 | $1,254.08 |
- 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
- $510.76 / $869.29 / $1,338.20
| Professional | | $510.76 | $869.29 | $1,338.20 |