- 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
- $907.63 / $1,272.00 / $1,491.19
| Professional | | $907.63 | $1,272.00 | $1,491.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.42 / $1,192.28 / $1,914.62
| Professional | | $861.42 | $1,192.28 | $1,914.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.97 / $1,610.76 / $2,046.93
| Professional | | $1,241.97 | $1,610.76 | $2,046.93 |
- 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
- $859.09 / $1,251.08 / $2,171.92
| Professional | | $859.09 | $1,251.08 | $2,171.92 |