- 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
- $722.83 / $1,031.88 / $1,158.05
| Professional | | $722.83 | $1,031.88 | $1,158.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.59 / $1,012.58 / $1,512.58
| Professional | | $731.59 | $1,012.58 | $1,512.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.78 / $1,286.98 / $1,681.70
| Professional | | $1,054.78 | $1,286.98 | $1,681.70 |
- 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
- $690.12 / $1,165.70 / $1,761.45
| Professional | | $690.12 | $1,165.70 | $1,761.45 |