- 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
- $1,162.41 / $1,245.38 / $1,275.24
| Professional | | $1,162.41 | $1,245.38 | $1,275.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.58 / $1,361.86 / $2,083.08
| Professional | | $1,157.58 | $1,361.86 | $2,083.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.16 / $1,351.98 / $2,398.06
| Professional | | $912.16 | $1,351.98 | $2,398.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.00 / $2,445.00 / $4,602.00
| Facility | | $1,334.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.45 / $1,168.60 / $1,819.95
| Professional | | $823.45 | $1,168.60 | $1,819.95 |