- 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
- $704.38 / $751.37 / $1,101.39
| Professional | | $704.38 | $751.37 | $1,101.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.07 / $1,060.31 / $1,446.05
| Professional | | $766.07 | $1,060.31 | $1,446.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.66 / $1,121.40 / $1,717.39
| Professional | | $881.66 | $1,121.40 | $1,717.39 |
- 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
- $617.03 / $1,010.10 / $1,737.33
| Professional | | $617.03 | $1,010.10 | $1,737.33 |