- 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
- $851.56 / $978.74 / $1,075.25
| Professional | | $851.56 | $978.74 | $1,075.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.02 / $1,140.02 / $1,661.69
| Professional | | $969.02 | $1,140.02 | $1,661.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.64 / $1,159.00 / $2,075.53
| Professional | | $771.64 | $1,159.00 | $2,075.53 |
- 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
- $649.46 / $910.51 / $1,341.80
| Professional | | $649.46 | $910.51 | $1,341.80 |