- 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 / $707.95 / $1,862.09
| Professional | | $562.34 | $707.95 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $602.56 / $1,023.29
| Professional | | $446.68 | $602.56 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $758.58 / $1,230.27
| Professional | | $208.93 | $758.58 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $6,025.60
| Facility | | $1,380.38 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $812.83 / $1,122.02
| Professional | | $524.81 | $812.83 | $1,122.02 |