- 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
- $973.85 / $1,288.16 / $1,616.76
| Professional | | $973.85 | $1,288.16 | $1,616.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.44 / $1,279.51 / $2,096.19
| Professional | | $924.44 | $1,279.51 | $2,096.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.78 / $1,579.09 / $2,204.66
| Professional | | $835.78 | $1,579.09 | $2,204.66 |
- 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
- $594.10 / $1,359.61 / $2,351.04
| Professional | | $594.10 | $1,359.61 | $2,351.04 |