- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $2,691.53
| Professional | | $912.01 | $1,047.13 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,023.29 / $1,819.70
| Professional | | $912.01 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $2,089.30
| Professional | | $1,230.27 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,290.87
| Professional | | $891.25 | $1,288.25 | $2,290.87 |