- 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
- $913.56 / $1,125.71 / $1,504.96
| Professional | | $913.56 | $1,125.71 | $1,504.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.69 / $1,312.58 / $2,338.98
| Professional | | $1,115.69 | $1,312.58 | $2,338.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.33 / $1,437.48 / $2,678.88
| Professional | | $1,205.33 | $1,437.48 | $2,678.88 |
- 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
- $1,016.83 / $1,602.20 / $2,502.06
| Professional | | $1,016.83 | $1,602.20 | $2,502.06 |