- 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
- $776.87 / $1,099.39 / $1,237.47
| Professional | | $776.87 | $1,099.39 | $1,237.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.60 / $1,055.51 / $1,607.63
| Professional | | $762.60 | $1,055.51 | $1,607.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.49 / $1,452.58 / $1,778.41
| Professional | | $1,099.49 | $1,452.58 | $1,778.41 |
- 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
- $746.40 / $1,232.73 / $1,845.33
| Professional | | $746.40 | $1,232.73 | $1,845.33 |