- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.24 / $1,069.43 / $1,344.23
| Professional | | $771.24 | $1,069.43 | $1,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.83 / $1,071.05 / $1,659.00
| Professional | | $773.83 | $1,071.05 | $1,659.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.23 / $1,320.43 / $1,796.21
| Professional | | $930.23 | $1,320.43 | $1,796.21 |
- 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
- $645.44 / $1,116.71 / $1,881.92
| Professional | | $645.44 | $1,116.71 | $1,881.92 |