- 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
- $924.66 / $1,056.51 / $1,692.38
| Professional | | $924.66 | $1,056.51 | $1,692.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.33 / $1,182.46 / $2,155.94
| Professional | | $854.33 | $1,182.46 | $2,155.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.72 / $1,774.93 / $2,160.27
| Professional | | $1,231.72 | $1,774.93 | $2,160.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $8,699.00 / $12,680.00
| Facility | | $3,219.00 | $8,699.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.66 / $1,497.42 / $2,313.26
| Professional | | $906.66 | $1,497.42 | $2,313.26 |