- 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
- $822.73 / $1,084.89 / $1,284.30
| Professional | | $822.73 | $1,084.89 | $1,284.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.30 / $1,103.53 / $1,476.02
| Professional | | $797.30 | $1,103.53 | $1,476.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.51 / $1,464.26 / $1,854.17
| Professional | | $1,149.51 | $1,464.26 | $1,854.17 |
- 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
- $772.39 / $1,140.74 / $1,686.49
| Professional | | $772.39 | $1,140.74 | $1,686.49 |