- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.30 / $2,090.73 / $3,955.04
| Facility | | $1,020.30 | $2,090.73 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.12 / $847.46 / $1,020.70
| Professional | | $730.12 | $847.46 | $1,020.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.00 / $1,052.33 / $1,487.98
| Professional | | $755.00 | $1,052.33 | $1,487.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.21 / $1,137.03 / $2,050.58
| Professional | | $886.21 | $1,137.03 | $2,050.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.96 / $1,174.09 / $2,121.63
| Professional | | $746.96 | $1,174.09 | $2,121.63 |