- 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
- $871.85 / $1,043.46 / $1,611.53
| Professional | | $871.85 | $1,043.46 | $1,611.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.65 / $1,200.91 / $1,980.75
| Professional | | $867.65 | $1,200.91 | $1,980.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.91 / $1,420.45 / $1,989.19
| Professional | | $1,200.91 | $1,420.45 | $1,989.19 |
- 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
- $857.68 / $1,352.48 / $2,250.23
| Professional | | $857.68 | $1,352.48 | $2,250.23 |