- 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
- $707.12 / $1,071.83 / $1,691.78
| Professional | | $707.12 | $1,071.83 | $1,691.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.82 / $1,710.38 / $2,346.98
| Professional | | $1,453.82 | $1,710.38 | $2,346.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.53 / $1,448.82 / $3,011.16
| Professional | | $1,265.53 | $1,448.82 | $3,011.16 |
- 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
- $927.83 / $1,683.69 / $2,973.40
| Professional | | $927.83 | $1,683.69 | $2,973.40 |