- 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
- $961.67 / $1,120.11 / $1,394.19
| Professional | | $961.67 | $1,120.11 | $1,394.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.84 / $1,448.06 / $2,144.91
| Professional | | $1,230.84 | $1,448.06 | $2,144.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.17 / $1,734.31 / $2,252.54
| Professional | | $1,224.17 | $1,734.31 | $2,252.54 |
- 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
- $908.30 / $1,283.03 / $2,405.30
| Professional | | $908.30 | $1,283.03 | $2,405.30 |