- 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
- $757.86 / $1,071.08 / $1,215.50
| Professional | | $757.86 | $1,071.08 | $1,215.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.75 / $1,047.40 / $1,571.48
| Professional | | $756.75 | $1,047.40 | $1,571.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.03 / $1,345.97 / $1,744.46
| Professional | | $1,091.03 | $1,345.97 | $1,744.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.34 / $1,082.98 / $1,782.65
| Professional | | $671.34 | $1,082.98 | $1,782.65 |