- 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
- $839.90 / $1,172.22 / $1,358.37
| Professional | | $839.90 | $1,172.22 | $1,358.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.97 / $1,104.46 / $1,756.08
| Professional | | $797.97 | $1,104.46 | $1,756.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.00 / $5,979.00 / $12,680.00
| Facility | | $2,609.00 | $5,979.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.80 / $1,311.03 / $1,992.06
| Professional | | $798.80 | $1,311.03 | $1,992.06 |