- 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
- $710.65 / $1,218.55 / $1,377.76
| Professional | | $710.65 | $1,218.55 | $1,377.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.43 / $1,260.51 / $2,096.15
| Professional | | $1,071.43 | $1,260.51 | $2,096.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.20 / $1,459.93 / $2,258.25
| Professional | | $1,007.20 | $1,459.93 | $2,258.25 |
- 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
- $1,049.06 / $1,399.68 / $2,169.04
| Professional | | $1,049.06 | $1,399.68 | $2,169.04 |