- 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
- $481.34 / $829.98 / $1,169.77
| Professional | | $481.34 | $829.98 | $1,169.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.66 / $1,099.86 / $1,476.19
| Professional | | $794.66 | $1,099.86 | $1,476.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.32 / $1,087.28 / $1,684.44
| Professional | | $882.32 | $1,087.28 | $1,684.44 |
- 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
- $669.10 / $1,050.58 / $1,532.11
| Professional | | $669.10 | $1,050.58 | $1,532.11 |