- 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
- $840.01 / $1,201.33 / $1,461.71
| Professional | | $840.01 | $1,201.33 | $1,461.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.71 / $1,188.53 / $1,738.81
| Professional | | $858.71 | $1,188.53 | $1,738.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.05 / $1,547.45 / $2,033.59
| Professional | | $1,238.05 | $1,547.45 | $2,033.59 |
- 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
- $859.87 / $1,437.47 / $1,972.48
| Professional | | $859.87 | $1,437.47 | $1,972.48 |