- 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
- $594.33 / $872.98 / $1,069.33
| Professional | | $594.33 | $872.98 | $1,069.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.41 / $835.16 / $1,445.77
| Professional | | $603.41 | $835.16 | $1,445.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.58 / $1,134.77 / $1,432.47
| Professional | | $838.58 | $1,134.77 | $1,432.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.32 / $992.94 / $1,532.05
| Professional | | $615.32 | $992.94 | $1,532.05 |