- 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
- $769.26 / $1,873.49 / $6,034.07
| Professional | | $769.26 | $1,873.49 | $6,034.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.77 / $3,371.01 / $6,252.25
| Professional | | $812.77 | $3,371.01 | $6,252.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.67 / $1,874.96 / $8,411.12
| Professional | | $1,165.67 | $1,874.96 | $8,411.12 |
- 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
- $2,370.78 / $4,829.41 / $7,748.07
| Professional | | $2,370.78 | $4,829.41 | $7,748.07 |