- 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
- $770.98 / $1,075.92 / $1,259.24
| Professional | | $770.98 | $1,075.92 | $1,259.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.75 / $1,008.65 / $1,629.51
| Professional | | $728.75 | $1,008.65 | $1,629.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.68 / $1,358.53 / $1,748.41
| Professional | | $1,050.68 | $1,358.53 | $1,748.41 |
- 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
- $754.42 / $1,211.94 / $1,848.49
| Professional | | $754.42 | $1,211.94 | $1,848.49 |