- 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
- $761.90 / $1,117.23 / $1,292.44
| Professional | | $761.90 | $1,117.23 | $1,292.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.84 / $1,069.67 / $1,704.52
| Professional | | $772.84 | $1,069.67 | $1,704.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.03 / $1,374.26 / $1,798.66
| Professional | | $1,073.03 | $1,374.26 | $1,798.66 |
- 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
- $715.16 / $1,226.03 / $1,931.86
| Professional | | $715.16 | $1,226.03 | $1,931.86 |