- 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
- $637.74 / $816.98 / $1,137.91
| Professional | | $637.74 | $816.98 | $1,137.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.34 / $880.74 / $1,487.05
| Professional | | $636.34 | $880.74 | $1,487.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.74 / $1,080.74 / $1,436.64
| Professional | | $880.74 | $1,080.74 | $1,436.64 |
- 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
- $579.91 / $969.76 / $1,541.40
| Professional | | $579.91 | $969.76 | $1,541.40 |