- 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
- $748.85 / $855.39 / $962.00
| Professional | | $748.85 | $855.39 | $962.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.69 / $1,018.46 / $1,457.42
| Professional | | $865.69 | $1,018.46 | $1,457.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.68 / $1,040.00 / $1,863.79
| Professional | | $672.68 | $1,040.00 | $1,863.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.76 / $763.90 / $1,188.29
| Professional | | $537.76 | $763.90 | $1,188.29 |