- 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
- $790.99 / $1,108.02 / $1,270.30
| Professional | | $790.99 | $1,108.02 | $1,270.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.69 / $1,087.46 / $1,586.78
| Professional | | $785.69 | $1,087.46 | $1,586.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.77 / $1,406.45 / $1,792.66
| Professional | | $1,132.77 | $1,406.45 | $1,792.66 |
- 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
- $789.45 / $1,242.59 / $1,800.01
| Professional | | $789.45 | $1,242.59 | $1,800.01 |