- 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
- $745.33 / $1,020.74 / $1,093.33
| Professional | | $745.33 | $1,020.74 | $1,093.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.81 / $1,091.54 / $1,844.17
| Professional | | $927.81 | $1,091.54 | $1,844.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.05 / $1,078.83 / $1,913.56
| Professional | | $729.05 | $1,078.83 | $1,913.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.39 / $1,021.94 / $1,453.73
| Professional | | $684.39 | $1,021.94 | $1,453.73 |