- 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
- $750.30 / $1,053.46 / $1,231.15
| Professional | | $750.30 | $1,053.46 | $1,231.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.55 / $989.00 / $1,572.37
| Professional | | $714.55 | $989.00 | $1,572.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.21 / $1,318.48 / $1,696.86
| Professional | | $1,030.21 | $1,318.48 | $1,696.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.00 / $5,979.00 / $12,680.00
| Facility | | $2,609.00 | $5,979.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.34 / $1,176.21 / $1,783.68
| Professional | | $732.34 | $1,176.21 | $1,783.68 |