- 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
- $960.32 / $1,374.12 / $1,577.94
| Professional | | $960.32 | $1,374.12 | $1,577.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.91 / $1,284.30 / $2,055.28
| Professional | | $927.91 | $1,284.30 | $2,055.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.81 / $1,710.77 / $2,216.29
| Professional | | $1,337.81 | $1,710.77 | $2,216.29 |
- 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
- $955.91 / $1,566.61 / $2,331.48
| Professional | | $955.91 | $1,566.61 | $2,331.48 |