- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.18 / $1,574.36 / $3,469.64
| Professional | | $741.18 | $1,574.36 | $3,469.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.67 / $1,540.53 / $2,809.71
| Professional | | $781.67 | $1,540.53 | $2,809.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.85 / $1,801.85 / $3,928.14
| Professional | | $1,121.85 | $1,801.85 | $3,928.14 |
- 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
- $1,453.10 / $2,836.73 / $4,405.45
| Professional | | $1,453.10 | $2,836.73 | $4,405.45 |