- 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
- $805.46 / $1,121.83 / $1,237.18
| Professional | | $805.46 | $1,121.83 | $1,237.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.52 / $1,297.08 / $2,002.95
| Professional | | $1,102.52 | $1,297.08 | $2,002.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,474.33 / $2,162.52
| Professional | | $250.00 | $1,474.33 | $2,162.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.67 / $1,123.97 / $2,315.71
| Professional | | $855.67 | $1,123.97 | $2,315.71 |