- 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
- $850.35 / $1,229.52 / $1,359.37
| Professional | | $850.35 | $1,229.52 | $1,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.06 / $1,205.61 / $1,762.29
| Professional | | $871.06 | $1,205.61 | $1,762.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.26 / $1,517.83 / $1,969.47
| Professional | | $1,233.26 | $1,517.83 | $1,969.47 |
- 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
- $827.23 / $1,365.18 / $2,109.19
| Professional | | $827.23 | $1,365.18 | $2,109.19 |