- 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
- $992.80 / $1,395.75 / $1,626.77
| Professional | | $992.80 | $1,395.75 | $1,626.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.04 / $1,303.85 / $2,078.16
| Professional | | $942.04 | $1,303.85 | $2,078.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.19 / $1,748.62 / $2,249.17
| Professional | | $1,358.19 | $1,748.62 | $2,249.17 |
- 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
- $993.66 / $1,387.29 / $2,357.42
| Professional | | $993.66 | $1,387.29 | $2,357.42 |