- 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
- $916.91 / $1,285.40 / $1,475.92
| Professional | | $916.91 | $1,285.40 | $1,475.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.39 / $1,204.69 / $1,920.04
| Professional | | $870.39 | $1,204.69 | $1,920.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.89 / $1,608.72 / $2,072.19
| Professional | | $1,254.89 | $1,608.72 | $2,072.19 |
- 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
- $894.00 / $1,292.42 / $2,178.06
| Professional | | $894.00 | $1,292.42 | $2,178.06 |