- 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
- $914.02 / $1,293.77 / $1,478.98
| Professional | | $914.02 | $1,293.77 | $1,478.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.31 / $1,276.55 / $1,904.75
| Professional | | $922.31 | $1,276.55 | $1,904.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.74 / $1,593.21 / $2,120.77
| Professional | | $1,329.74 | $1,593.21 | $2,120.77 |
- 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
- $741.96 / $1,322.72 / $2,160.69
| Professional | | $741.96 | $1,322.72 | $2,160.69 |