- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.81 / $3,955.04 / $5,496.04
| Facility | | $1,639.81 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.37 / $1,001.31 / $1,223.58
| Professional | | $863.37 | $1,001.31 | $1,223.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.00 / $1,357.65 / $1,775.27
| Professional | | $1,154.00 | $1,357.65 | $1,775.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.01 / $1,620.82 / $2,094.28
| Professional | | $1,143.01 | $1,620.82 | $2,094.28 |
- 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
- $843.92 / $1,196.16 / $2,237.38
| Professional | | $843.92 | $1,196.16 | $2,237.38 |