- 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
- $696.12 / $967.55 / $1,121.29
| Professional | | $696.12 | $967.55 | $1,121.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.59 / $984.90 / $1,450.40
| Professional | | $711.59 | $984.90 | $1,450.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.94 / $1,223.80 / $1,615.59
| Professional | | $1,025.94 | $1,223.80 | $1,615.59 |
- 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
- $699.86 / $1,119.86 / $1,705.34
| Professional | | $699.86 | $1,119.86 | $1,705.34 |