- 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
- $839.15 / $1,162.09 / $1,337.32
| Professional | | $839.15 | $1,162.09 | $1,337.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.72 / $1,113.80 / $1,704.75
| Professional | | $804.72 | $1,113.80 | $1,704.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.22 / $1,489.45 / $1,883.29
| Professional | | $1,160.22 | $1,489.45 | $1,883.29 |
- 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
- $822.51 / $1,199.58 / $1,933.83
| Professional | | $822.51 | $1,199.58 | $1,933.83 |