- 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
- $738.22 / $1,072.24 / $1,154.33
| Professional | | $738.22 | $1,072.24 | $1,154.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.88 / $1,218.68 / $1,821.09
| Professional | | $1,035.88 | $1,218.68 | $1,821.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.50 / $1,242.76 / $2,220.66
| Professional | | $841.50 | $1,242.76 | $2,220.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.30 / $991.03 / $1,460.47
| Professional | | $771.30 | $991.03 | $1,460.47 |