- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.48 / $1,511.25 / $1,521.47
| Professional | | $822.48 | $1,511.25 | $1,521.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.61 / $1,647.78 / $2,388.33
| Professional | | $1,400.61 | $1,647.78 | $2,388.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.84 / $1,713.26 / $2,903.22
| Professional | | $1,217.84 | $1,713.26 | $2,903.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.58 / $1,800.55 / $2,829.51
| Professional | | $1,201.58 | $1,800.55 | $2,829.51 |