- 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
- $763.70 / $1,086.45 / $1,221.33
| Professional | | $763.70 | $1,086.45 | $1,221.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.31 / $1,053.72 / $1,577.41
| Professional | | $761.31 | $1,053.72 | $1,577.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.61 / $1,356.73 / $1,757.28
| Professional | | $1,097.61 | $1,356.73 | $1,757.28 |
- 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
- $737.53 / $1,218.08 / $1,881.35
| Professional | | $737.53 | $1,218.08 | $1,881.35 |