- 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
- $811.93 / $1,543.87 / $1,655.68
| Professional | | $811.93 | $1,543.87 | $1,655.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.68 / $1,584.33 / $2,474.69
| Professional | | $1,346.68 | $1,584.33 | $2,474.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.48 / $1,824.93 / $2,803.62
| Professional | | $1,275.48 | $1,824.93 | $2,803.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.54 / $1,779.26 / $3,641.86
| Professional | | $1,421.54 | $1,779.26 | $3,641.86 |