- 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
- $730.66 / $1,024.08 / $1,185.38
| Professional | | $730.66 | $1,024.08 | $1,185.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.15 / $964.92 / $1,519.36
| Professional | | $697.15 | $964.92 | $1,519.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.13 / $1,271.29 / $1,645.41
| Professional | | $1,005.13 | $1,271.29 | $1,645.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,164.00 / $11,950.00
| Facility | | $2,838.00 | $5,164.00 | $11,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.60 / $1,140.54 / $1,723.53
| Professional | | $710.60 | $1,140.54 | $1,723.53 |