- 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
- $807.73 / $1,131.39 / $1,320.43
| Professional | | $807.73 | $1,131.39 | $1,320.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.08 / $1,063.08 / $1,683.01
| Professional | | $768.08 | $1,063.08 | $1,683.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.36 / $1,412.42 / $1,819.67
| Professional | | $1,107.36 | $1,412.42 | $1,819.67 |
- 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
- $785.52 / $1,261.33 / $1,909.18
| Professional | | $785.52 | $1,261.33 | $1,909.18 |