- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $2,884.03
| Professional | | $933.25 | $1,071.52 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,778.28
| Professional | | $912.01 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $2,137.96
| Professional | | $1,148.15 | $1,348.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,230.27 / $2,290.87
| Professional | | $831.76 | $1,230.27 | $2,290.87 |