- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,778.87 / $3,756.06 / $3,955.04
| Facility | | $2,778.87 | $3,756.06 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.59 / $421.38 / $1,007.54
| Professional | | $178.59 | $421.38 | $1,007.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.74 / $1,004.21 / $1,434.58
| Professional | | $255.74 | $1,004.21 | $1,434.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.10 / $505.23 / $2,267.60
| Professional | | $258.10 | $505.23 | $2,267.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.80 / $1,571.83 / $3,087.66
| Professional | | $1,001.80 | $1,571.83 | $3,087.66 |