- 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
- $831.20 / $1,166.31 / $1,381.30
| Professional | | $831.20 | $1,166.31 | $1,381.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.26 / $1,095.16 / $1,765.81
| Professional | | $791.26 | $1,095.16 | $1,765.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.78 / $1,437.05 / $1,903.69
| Professional | | $1,140.78 | $1,437.05 | $1,903.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.34 / $1,319.57 / $2,003.09
| Professional | | $821.34 | $1,319.57 | $2,003.09 |