- 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
- $701.86 / $1,082.89 / $1,263.81
| Professional | | $701.86 | $1,082.89 | $1,263.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.93 / $1,211.68 / $1,899.76
| Professional | | $1,029.93 | $1,211.68 | $1,899.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,633.32 / $2,401.42
| Professional | | $300.00 | $1,633.32 | $2,401.42 |
- 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
- $940.75 / $1,491.88 / $2,392.03
| Professional | | $940.75 | $1,491.88 | $2,392.03 |