- 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
- $918.45 / $1,218.60 / $1,518.63
| Professional | | $918.45 | $1,218.60 | $1,518.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.03 / $1,205.58 / $1,830.62
| Professional | | $871.03 | $1,205.58 | $1,830.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.81 / $1,499.53 / $2,094.71
| Professional | | $1,255.81 | $1,499.53 | $2,094.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.10 / $1,451.98 / $2,076.62
| Professional | | $903.10 | $1,451.98 | $2,076.62 |