- 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
- $626.79 / $870.85 / $1,012.65
| Professional | | $626.79 | $870.85 | $1,012.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.00 / $838.75 / $1,291.45
| Professional | | $606.00 | $838.75 | $1,291.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.69 / $1,075.94 / $1,407.46
| Professional | | $873.69 | $1,075.94 | $1,407.46 |
- 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
- $492.41 / $877.84 / $1,465.00
| Professional | | $492.41 | $877.84 | $1,465.00 |