- 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
- $369.93 / $594.78 / $2,174.50
| Professional | | $369.93 | $594.78 | $2,174.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.85 / $1,926.57 / $2,752.24
| Professional | | $436.85 | $1,926.57 | $2,752.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.50 / $848.47 / $4,154.97
| Professional | | $604.50 | $848.47 | $4,154.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.60 / $2,505.39 / $3,639.00
| Professional | | $1,474.60 | $2,505.39 | $3,639.00 |