- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.22 / $881.31 / $1,024.27
| Professional | | $631.22 | $881.31 | $1,024.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.40 / $831.00 / $1,311.52
| Professional | | $600.40 | $831.00 | $1,311.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.63 / $1,278.47 / $1,417.01
| Professional | | $865.63 | $1,278.47 | $1,417.01 |
- 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
- $626.02 / $994.26 / $1,487.77
| Professional | | $626.02 | $994.26 | $1,487.77 |