- 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
- $885.24 / $1,242.09 / $1,452.43
| Professional | | $885.24 | $1,242.09 | $1,452.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.40 / $1,163.18 / $1,852.92
| Professional | | $840.40 | $1,163.18 | $1,852.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.65 / $1,799.09 / $2,002.12
| Professional | | $1,211.65 | $1,799.09 | $2,002.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.51 / $1,387.80 / $2,101.91
| Professional | | $884.51 | $1,387.80 | $2,101.91 |