- 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
- $616.60 / $776.25 / $1,995.26
| Professional | | $616.60 | $776.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $660.69 / $1,096.48
| Professional | | $501.19 | $660.69 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $851.14 / $1,348.96
| Professional | | $89.13 | $851.14 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,912.51
| Facility | | $2,570.40 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $851.14 / $1,258.93
| Professional | | $575.44 | $851.14 | $1,258.93 |