- 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
- $905.76 / $1,004.15 / $1,188.08
| Professional | | $905.76 | $1,004.15 | $1,188.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.72 / $1,111.44 / $1,757.78
| Professional | | $944.72 | $1,111.44 | $1,757.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,211.82 / $1,859.26
| Professional | | $150.00 | $1,211.82 | $1,859.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.36 / $1,022.60 / $1,955.03
| Professional | | $796.36 | $1,022.60 | $1,955.03 |