- 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
- $904.89 / $1,259.76 / $1,442.93
| Professional | | $904.89 | $1,259.76 | $1,442.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.04 / $1,197.28 / $1,844.69
| Professional | | $865.04 | $1,197.28 | $1,844.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.16 / $1,619.93 / $2,030.99
| Professional | | $1,247.16 | $1,619.93 | $2,030.99 |
- 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
- $881.19 / $1,305.80 / $2,092.58
| Professional | | $881.19 | $1,305.80 | $2,092.58 |