- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.67 / $1,051.81 / $1,413.20
| Professional | | $975.67 | $1,051.81 | $1,413.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.41 / $1,598.13 / $1,974.35
| Professional | | $1,358.41 | $1,598.13 | $1,974.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.61 / $1,913.20 / $2,479.31
| Professional | | $1,348.61 | $1,913.20 | $2,479.31 |
- 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
- $1,062.01 / $1,447.26 / $2,647.84
| Professional | | $1,062.01 | $1,447.26 | $2,647.84 |