- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.44 / $1,296.22 / $1,493.12
| Professional | | $915.44 | $1,296.22 | $1,493.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.68 / $1,362.88 / $1,911.21
| Professional | | $984.68 | $1,362.88 | $1,911.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.81 / $1,657.32 / $2,306.92
| Professional | | $1,355.81 | $1,657.32 | $2,306.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.25 / $1,554.16 / $2,331.55
| Professional | | $917.25 | $1,554.16 | $2,331.55 |