- 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
- $796.95 / $1,116.27 / $1,302.78
| Professional | | $796.95 | $1,116.27 | $1,302.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.22 / $1,049.44 / $1,659.62
| Professional | | $758.22 | $1,049.44 | $1,659.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.17 / $1,391.09 / $1,794.73
| Professional | | $1,093.17 | $1,391.09 | $1,794.73 |
- 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
- $753.24 / $1,244.04 / $1,882.65
| Professional | | $753.24 | $1,244.04 | $1,882.65 |