- 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
- $210.19 / $764.00 / $1,943.86
| Professional | | $210.19 | $764.00 | $1,943.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.90 / $793.69 / $2,962.96
| Professional | | $425.90 | $793.69 | $2,962.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.32 / $827.71 / $3,171.27
| Professional | | $356.32 | $827.71 | $3,171.27 |
- 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
- $1,531.25 / $2,104.96 / $3,986.65
| Professional | | $1,531.25 | $2,104.96 | $3,986.65 |