- 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
- $760.20 / $1,065.26 / $1,226.59
| Professional | | $760.20 | $1,065.26 | $1,226.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.51 / $1,002.78 / $1,569.51
| Professional | | $724.51 | $1,002.78 | $1,569.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.56 / $1,324.00 / $1,711.93
| Professional | | $1,044.56 | $1,324.00 | $1,711.93 |
- 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
- $739.25 / $1,201.19 / $1,780.41
| Professional | | $739.25 | $1,201.19 | $1,780.41 |