- 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
- $962.26 / $1,364.05 / $1,576.63
| Professional | | $962.26 | $1,364.05 | $1,576.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $1,722.62 / $1,722.62
| Professional | | $0.02 | $1,722.62 | $1,722.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.62 / $1,680.60 / $2,215.42
| Professional | | $1,365.62 | $1,680.60 | $2,215.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.81 / $1,566.00 / $2,233.26
| Professional | | $929.81 | $1,566.00 | $2,233.26 |