- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,695.56
| Facility | | $3,706.14 | $3,955.04 | $5,695.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.43 / $1,396.55 / $1,638.59
| Professional | | $1,011.43 | $1,396.55 | $1,638.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.75 / $1,331.14 / $2,106.52
| Professional | | $961.75 | $1,331.14 | $2,106.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.60 / $1,761.75 / $2,261.52
| Professional | | $1,386.60 | $1,761.75 | $2,261.52 |
- 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
- $949.16 / $1,567.61 / $2,415.61
| Professional | | $949.16 | $1,567.61 | $2,415.61 |