- 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
- $992.62 / $1,075.00 / $1,087.63
| Professional | | $992.62 | $1,075.00 | $1,087.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.86 / $1,164.54 / $1,855.56
| Professional | | $989.86 | $1,164.54 | $1,855.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.62 / $1,156.10 / $2,067.71
| Professional | | $780.62 | $1,156.10 | $2,067.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.49 / $992.05 / $1,543.32
| Professional | | $703.49 | $992.05 | $1,543.32 |