- 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
- $921.66 / $1,291.92 / $1,504.77
| Professional | | $921.66 | $1,291.92 | $1,504.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.86 / $1,210.88 / $1,929.43
| Professional | | $874.86 | $1,210.88 | $1,929.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.33 / $1,623.34 / $2,082.88
| Professional | | $1,261.33 | $1,623.34 | $2,082.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,505.00 / $7,819.00 / $19,195.00
| Facility | | $4,505.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.59 / $1,443.78 / $2,188.71
| Professional | | $898.59 | $1,443.78 | $2,188.71 |