- 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
- $924.63 / $1,316.53 / $1,535.31
| Professional | | $924.63 | $1,316.53 | $1,535.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.44 / $1,204.76 / $1,964.38
| Professional | | $870.44 | $1,204.76 | $1,964.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.96 / $1,633.87 / $2,119.44
| Professional | | $1,254.96 | $1,633.87 | $2,119.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.90 / $1,435.29 / $2,228.36
| Professional | | $888.90 | $1,435.29 | $2,228.36 |