- 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
- $922.26 / $1,264.27 / $1,742.25
| Professional | | $922.26 | $1,264.27 | $1,742.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.39 / $1,301.58 / $2,250.56
| Professional | | $940.39 | $1,301.58 | $2,250.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.58 / $1,667.00 / $2,178.12
| Professional | | $1,301.58 | $1,667.00 | $2,178.12 |
- 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
- $938.24 / $1,466.00 / $2,439.94
| Professional | | $938.24 | $1,466.00 | $2,439.94 |