- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.25 / $848.38 / $1,161.94
| Professional | | $726.25 | $848.38 | $1,161.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.13 / $1,000.87 / $1,489.71
| Professional | | $723.13 | $1,000.87 | $1,489.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.58 / $1,300.55 / $1,644.09
| Professional | | $1,042.58 | $1,300.55 | $1,644.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.16 / $1,139.63 / $1,741.69
| Professional | | $713.16 | $1,139.63 | $1,741.69 |