- 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
- $767.14 / $1,109.29 / $1,410.59
| Professional | | $767.14 | $1,109.29 | $1,410.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.43 / $1,138.31 / $1,675.84
| Professional | | $822.43 | $1,138.31 | $1,675.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.20 / $1,410.53 / $1,771.54
| Professional | | $1,066.20 | $1,410.53 | $1,771.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.67 / $1,224.29 / $1,901.05
| Professional | | $706.67 | $1,224.29 | $1,901.05 |