- 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
- $625.64 / $872.61 / $1,004.64
| Professional | | $625.64 | $872.61 | $1,004.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.98 / $824.88 / $1,298.41
| Professional | | $595.98 | $824.88 | $1,298.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.25 / $1,084.78 / $1,402.27
| Professional | | $859.25 | $1,084.78 | $1,402.27 |
- 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
- $588.53 / $972.00 / $1,472.89
| Professional | | $588.53 | $972.00 | $1,472.89 |