- 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
- $814.03 / $906.23 / $1,033.05
| Professional | | $814.03 | $906.23 | $1,033.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.01 / $1,095.31 / $1,547.71
| Professional | | $931.01 | $1,095.31 | $1,547.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.63 / $1,116.33 / $1,998.63
| Professional | | $725.63 | $1,116.33 | $1,998.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.09 / $883.83 / $1,284.02
| Professional | | $581.09 | $883.83 | $1,284.02 |