- 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
- $787.56 / $1,154.91 / $1,901.23
| Professional | | $787.56 | $1,154.91 | $1,901.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.22 / $1,502.04 / $2,419.69
| Professional | | $1,085.22 | $1,502.04 | $2,419.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.77 / $1,851.85 / $2,600.32
| Professional | | $888.77 | $1,851.85 | $2,600.32 |
- 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
- $616.00 / $1,767.48 / $2,744.87
| Professional | | $616.00 | $1,767.48 | $2,744.87 |