- 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
- $694.64 / $941.97 / $1,133.35
| Professional | | $694.64 | $941.97 | $1,133.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.63 / $889.45 / $1,442.74
| Professional | | $642.63 | $889.45 | $1,442.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.51 / $1,165.55 / $1,541.96
| Professional | | $926.51 | $1,165.55 | $1,541.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.10 / $961.73 / $1,636.62
| Professional | | $613.10 | $961.73 | $1,636.62 |