- 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
- $804.03 / $1,123.85 / $1,317.04
| Professional | | $804.03 | $1,123.85 | $1,317.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.84 / $1,057.21 / $1,683.14
| Professional | | $763.84 | $1,057.21 | $1,683.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.26 / $1,398.18 / $1,811.80
| Professional | | $1,101.26 | $1,398.18 | $1,811.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.41 / $1,255.88 / $1,934.71
| Professional | | $760.41 | $1,255.88 | $1,934.71 |