- 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
- $952.39 / $1,009.18 / $1,460.97
| Professional | | $952.39 | $1,009.18 | $1,460.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.35 / $1,359.66 / $1,951.72
| Professional | | $982.35 | $1,359.66 | $1,951.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.66 / $1,526.74 / $2,243.90
| Professional | | $1,195.66 | $1,526.74 | $2,243.90 |
- 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
- $833.86 / $1,411.20 / $2,344.87
| Professional | | $833.86 | $1,411.20 | $2,344.87 |