- 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
- $994.85 / $1,397.88 / $1,632.19
| Professional | | $994.85 | $1,397.88 | $1,632.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.96 / $1,306.52 / $2,090.17
| Professional | | $943.96 | $1,306.52 | $2,090.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.96 / $1,760.08 / $2,252.76
| Professional | | $1,360.96 | $1,760.08 | $2,252.76 |
- 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
- $971.51 / $1,532.30 / $2,371.06
| Professional | | $971.51 | $1,532.30 | $2,371.06 |