- 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
- $825.42 / $1,150.32 / $1,278.65
| Professional | | $825.42 | $1,150.32 | $1,278.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.04 / $1,096.25 / $1,675.91
| Professional | | $792.04 | $1,096.25 | $1,675.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.92 / $1,521.60 / $1,851.86
| Professional | | $1,141.92 | $1,521.60 | $1,851.86 |
- 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
- $804.30 / $1,283.64 / $1,984.02
| Professional | | $804.30 | $1,283.64 | $1,984.02 |