- 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
- $912.39 / $1,214.81 / $1,673.14
| Professional | | $912.39 | $1,214.81 | $1,673.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.66 / $1,253.50 / $2,149.06
| Professional | | $905.66 | $1,253.50 | $2,149.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.49 / $1,602.09 / $2,091.44
| Professional | | $1,253.49 | $1,602.09 | $2,091.44 |
- 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
- $877.78 / $1,421.17 / $2,241.83
| Professional | | $877.78 | $1,421.17 | $2,241.83 |