- 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
- $887.61 / $1,244.79 / $1,456.52
| Professional | | $887.61 | $1,244.79 | $1,456.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.75 / $1,166.44 / $1,857.11
| Professional | | $842.75 | $1,166.44 | $1,857.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.03 / $1,548.86 / $2,006.54
| Professional | | $1,215.03 | $1,548.86 | $2,006.54 |
- 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
- $886.47 / $1,390.86 / $2,106.67
| Professional | | $886.47 | $1,390.86 | $2,106.67 |