- 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
- $866.94 / $1,021.35 / $1,253.07
| Professional | | $866.94 | $1,021.35 | $1,253.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.82 / $1,379.79 / $2,033.18
| Professional | | $1,172.82 | $1,379.79 | $2,033.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.14 / $1,649.13 / $2,136.62
| Professional | | $1,163.14 | $1,649.13 | $2,136.62 |
- 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
- $807.41 / $1,160.05 / $2,189.69
| Professional | | $807.41 | $1,160.05 | $2,189.69 |