- 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
- $788.43 / $1,104.92 / $1,259.71
| Professional | | $788.43 | $1,104.92 | $1,259.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.69 / $1,036.25 / $1,652.90
| Professional | | $748.69 | $1,036.25 | $1,652.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.42 / $1,405.37 / $1,781.25
| Professional | | $1,079.42 | $1,405.37 | $1,781.25 |
- 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
- $708.24 / $1,077.66 / $1,770.65
| Professional | | $708.24 | $1,077.66 | $1,770.65 |