- 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
- $729.80 / $1,019.18 / $1,161.49
| Professional | | $729.80 | $1,019.18 | $1,161.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.58 / $964.12 / $1,518.01
| Professional | | $696.58 | $964.12 | $1,518.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.29 / $1,254.91 / $1,643.97
| Professional | | $1,004.29 | $1,254.91 | $1,643.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.28 / $936.28 / $1,722.00
| Professional | | $726.28 | $936.28 | $1,722.00 |