- 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
- $889.11 / $1,248.21 / $1,414.58
| Professional | | $889.11 | $1,248.21 | $1,414.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.06 / $1,168.25 / $1,861.61
| Professional | | $844.06 | $1,168.25 | $1,861.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.92 / $1,565.13 / $2,010.01
| Professional | | $1,216.92 | $1,565.13 | $2,010.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.18 / $1,393.26 / $2,111.76
| Professional | | $867.18 | $1,393.26 | $2,111.76 |