- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.62 / $1,327.35 / $1,536.15
| Professional | | $946.62 | $1,327.35 | $1,536.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.71 / $1,243.88 / $1,983.52
| Professional | | $898.71 | $1,243.88 | $1,983.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.72 / $1,665.02 / $2,139.59
| Professional | | $1,295.72 | $1,665.02 | $2,139.59 |
- 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
- $923.18 / $1,501.28 / $2,250.07
| Professional | | $923.18 | $1,501.28 | $2,250.07 |