- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.03 / $2,365.01 / $3,731.82
| Facility | | $1,015.03 | $2,365.01 | $3,731.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.37 / $1,015.03 / $1,419.66
| Professional | | $937.37 | $1,015.03 | $1,419.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.83 / $1,278.71 / $2,568.53
| Professional | | $1,150.83 | $1,278.71 | $2,568.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.98 / $2,283.44 / $3,202.36
| Professional | | $1,184.98 | $2,283.44 | $3,202.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.46 / $2,485.92 / $2,485.92
| Professional | | $1,119.46 | $2,485.92 | $2,485.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.50 / $1,519.61 / $3,148.06
| Professional | | $923.50 | $1,519.61 | $3,148.06 |