- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.72 / $1,001.76 / $1,029.89
| Professional | | $762.72 | $1,001.76 | $1,029.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.13 / $1,114.27 / $1,708.93
| Professional | | $947.13 | $1,114.27 | $1,708.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.33 / $1,201.61 / $2,182.30
| Professional | | $1,004.33 | $1,201.61 | $2,182.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.76 / $1,221.43 / $2,223.75
| Professional | | $781.76 | $1,221.43 | $2,223.75 |