- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,994.06 / $4,636.95 / $6,249.12
| Facility | | $3,994.06 | $4,636.95 | $6,249.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.73 / $981.40 / $1,344.13
| Professional | | $846.73 | $981.40 | $1,344.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.47 / $887.66 / $1,120.11
| Facility | | $129.47 | $887.66 | $1,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.72 / $136.00 / $942.41
| Professional | | $128.72 | $136.00 | $942.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.34 / $1,095.34 / $1,095.34
| Facility | | $1,095.34 | $1,095.34 | $1,095.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.30 / $1,161.60 / $3,763.44
| Professional | | $860.30 | $1,161.60 | $3,763.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,904.61 / $3,910.33 / $4,782.80
| Facility | | $2,904.61 | $3,910.33 | $4,782.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.58 / $1,140.83 / $1,864.13
| Professional | | $644.58 | $1,140.83 | $1,864.13 |