- 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
- $665.37 / $923.17 / $1,079.48
| Professional | | $665.37 | $923.17 | $1,079.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.80 / $878.62 / $1,374.23
| Professional | | $634.80 | $878.62 | $1,374.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.23 / $1,145.61 / $1,485.39
| Professional | | $915.23 | $1,145.61 | $1,485.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.59 / $1,029.61 / $1,558.89
| Professional | | $601.59 | $1,029.61 | $1,558.89 |