- 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
- $720.90 / $926.25 / $1,303.52
| Professional | | $720.90 | $926.25 | $1,303.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.84 / $994.93 / $1,695.61
| Professional | | $718.84 | $994.93 | $1,695.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.92 / $1,223.66 / $1,632.11
| Professional | | $994.92 | $1,223.66 | $1,632.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,299.00 / $4,374.00 / $9,622.00
| Facility | | $2,299.00 | $4,374.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.46 / $1,131.32 / $1,968.27
| Professional | | $657.46 | $1,131.32 | $1,968.27 |