- 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
- $1,018.94 / $1,353.55 / $1,448.49
| Professional | | $1,018.94 | $1,353.55 | $1,448.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.31 / $1,208.59 / $1,949.22
| Professional | | $1,027.31 | $1,208.59 | $1,949.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.06 / $5,109.06 / $5,109.06
| Facility | | $5,109.06 | $5,109.06 | $5,109.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.80 / $1,991.16 / $2,376.42
| Professional | | $1,226.80 | $1,991.16 | $2,376.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.69 / $1,481.43 / $2,337.80
| Professional | | $1,076.69 | $1,481.43 | $2,337.80 |