- 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
- $773.75 / $1,079.22 / $1,243.58
| Professional | | $773.75 | $1,079.22 | $1,243.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.98 / $1,051.86 / $1,583.73
| Professional | | $759.98 | $1,051.86 | $1,583.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.70 / $1,380.66 / $1,759.02
| Professional | | $1,095.70 | $1,380.66 | $1,759.02 |
- 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
- $742.50 / $1,130.80 / $1,796.56
| Professional | | $742.50 | $1,130.80 | $1,796.56 |