- 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
- $802.92 / $1,138.09 / $1,336.83
| Professional | | $802.92 | $1,138.09 | $1,336.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.07 / $1,022.93 / $1,693.57
| Professional | | $739.07 | $1,022.93 | $1,693.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.55 / $1,424.35 / $1,835.18
| Professional | | $1,065.55 | $1,424.35 | $1,835.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.24 / $1,272.08 / $1,921.15
| Professional | | $706.24 | $1,272.08 | $1,921.15 |