- 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
- $1,005.45 / $1,370.20 / $1,838.02
| Professional | | $1,005.45 | $1,370.20 | $1,838.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.05 / $1,338.48 / $2,387.32
| Professional | | $967.05 | $1,338.48 | $2,387.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.47 / $1,815.32 / $2,242.17
| Professional | | $1,338.47 | $1,815.32 | $2,242.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.25 / $1,554.21 / $2,305.82
| Professional | | $965.25 | $1,554.21 | $2,305.82 |