- 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
- $779.83 / $1,094.57 / $1,417.92
| Professional | | $779.83 | $1,094.57 | $1,417.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.21 / $1,323.47 / $1,749.09
| Professional | | $956.21 | $1,323.47 | $1,749.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.16 / $1,422.37 / $2,297.01
| Professional | | $896.16 | $1,422.37 | $2,297.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.98 / $1,406.73 / $2,118.01
| Professional | | $660.98 | $1,406.73 | $2,118.01 |