- 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
- $651.71 / $830.31 / $1,038.95
| Professional | | $651.71 | $830.31 | $1,038.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.49 / $857.42 / $1,188.10
| Professional | | $619.49 | $857.42 | $1,188.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.14 / $1,117.47 / $1,463.63
| Professional | | $893.14 | $1,117.47 | $1,463.63 |
- 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
- $651.75 / $1,034.58 / $1,462.25
| Professional | | $651.75 | $1,034.58 | $1,462.25 |