- 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
- $910.93 / $1,278.02 / $1,495.02
| Professional | | $910.93 | $1,278.02 | $1,495.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.63 / $1,196.72 / $1,909.11
| Professional | | $864.63 | $1,196.72 | $1,909.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.58 / $1,819.25 / $2,060.60
| Professional | | $1,246.58 | $1,819.25 | $2,060.60 |
- 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
- $912.82 / $1,428.34 / $2,199.52
| Professional | | $912.82 | $1,428.34 | $2,199.52 |