- 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
- $504.82 / $719.93 / $1,132.35
| Professional | | $504.82 | $719.93 | $1,132.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.39 / $710.16 / $1,309.91
| Professional | | $501.39 | $710.16 | $1,309.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.60 / $964.94 / $1,460.48
| Professional | | $654.60 | $964.94 | $1,460.48 |
- 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
- $579.47 / $936.73 / $1,439.74
| Professional | | $579.47 | $936.73 | $1,439.74 |