- 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
- $738.66 / $1,028.34 / $1,184.85
| Professional | | $738.66 | $1,028.34 | $1,184.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.76 / $1,008.66 / $1,498.95
| Professional | | $728.76 | $1,008.66 | $1,498.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.69 / $1,314.68 / $1,674.56
| Professional | | $1,050.69 | $1,314.68 | $1,674.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,164.00 / $9,622.00
| Facility | | $2,838.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.81 / $1,160.74 / $1,754.64
| Professional | | $702.81 | $1,160.74 | $1,754.64 |