- 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
- $926.78 / $1,300.50 / $1,529.45
| Professional | | $926.78 | $1,300.50 | $1,529.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.59 / $1,217.42 / $1,943.26
| Professional | | $879.59 | $1,217.42 | $1,943.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.15 / $1,794.80 / $2,097.67
| Professional | | $1,268.15 | $1,794.80 | $2,097.67 |
- 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
- $908.43 / $1,468.90 / $2,204.39
| Professional | | $908.43 | $1,468.90 | $2,204.39 |