- 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
- $688.21 / $959.96 / $1,122.95
| Professional | | $688.21 | $959.96 | $1,122.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.04 / $905.26 / $1,430.62
| Professional | | $654.04 | $905.26 | $1,430.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.98 / $1,219.82 / $1,545.12
| Professional | | $942.98 | $1,219.82 | $1,545.12 |
- 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
- $667.24 / $1,071.01 / $1,650.27
| Professional | | $667.24 | $1,071.01 | $1,650.27 |