- 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
- $817.87 / $843.82 / $1,621.04
| Professional | | $817.87 | $843.82 | $1,621.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.97 / $1,187.51 / $1,533.42
| Professional | | $857.97 | $1,187.51 | $1,533.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.58 / $1,331.08 / $1,951.84
| Professional | | $1,059.58 | $1,331.08 | $1,951.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.20 / $1,150.01 / $1,842.30
| Professional | | $732.20 | $1,150.01 | $1,842.30 |