- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.67 / $894.25 / $1,030.44
| Professional | | $640.67 | $894.25 | $1,030.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.10 / $843.05 / $1,331.25
| Professional | | $609.10 | $843.05 | $1,331.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.18 / $1,113.16 / $1,437.94
| Professional | | $878.18 | $1,113.16 | $1,437.94 |
- 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
- $595.90 / $895.79 / $1,536.00
| Professional | | $595.90 | $895.79 | $1,536.00 |