- 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
- $749.72 / $1,059.60 / $1,219.17
| Professional | | $749.72 | $1,059.60 | $1,219.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.18 / $1,034.15 / $1,544.51
| Professional | | $747.18 | $1,034.15 | $1,544.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.24 / $1,330.71 / $1,722.34
| Professional | | $1,077.24 | $1,330.71 | $1,722.34 |
- 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
- $704.14 / $1,193.86 / $1,844.16
| Professional | | $704.14 | $1,193.86 | $1,844.16 |