- 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
- $725.50 / $1,011.14 / $1,207.01
| Professional | | $725.50 | $1,011.14 | $1,207.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.73 / $961.57 / $1,565.99
| Professional | | $694.73 | $961.57 | $1,565.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.43 / $1,243.21 / $1,652.00
| Professional | | $790.43 | $1,243.21 | $1,652.00 |
- 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
- $550.86 / $1,030.35 / $1,764.01
| Professional | | $550.86 | $1,030.35 | $1,764.01 |