- 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
- $794.24 / $1,077.39 / $1,331.04
| Professional | | $794.24 | $1,077.39 | $1,331.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.30 / $1,014.95 / $1,588.96
| Professional | | $733.30 | $1,014.95 | $1,588.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.24 / $1,415.58 / $1,770.36
| Professional | | $1,057.24 | $1,415.58 | $1,770.36 |
- 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
- $761.09 / $1,211.15 / $1,802.48
| Professional | | $761.09 | $1,211.15 | $1,802.48 |