- 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
- $812.68 / $1,124.70 / $1,332.41
| Professional | | $812.68 | $1,124.70 | $1,332.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.09 / $1,079.71 / $1,647.84
| Professional | | $780.09 | $1,079.71 | $1,647.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.70 / $1,454.95 / $1,838.14
| Professional | | $1,124.70 | $1,454.95 | $1,838.14 |
- 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
- $795.41 / $1,274.14 / $1,869.27
| Professional | | $795.41 | $1,274.14 | $1,869.27 |