- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.97 / $1,291.59 / $1,529.50
| Professional | | $916.97 | $1,291.59 | $1,529.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.91 / $1,197.10 / $1,994.74
| Professional | | $864.91 | $1,197.10 | $1,994.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.99 / $1,697.12 / $2,081.25
| Professional | | $1,246.99 | $1,697.12 | $2,081.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.47 / $1,460.34 / $2,221.15
| Professional | | $919.47 | $1,460.34 | $2,221.15 |