- 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
- $759.36 / $1,032.36 / $1,225.24
| Professional | | $759.36 | $1,032.36 | $1,225.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.17 / $1,002.31 / $1,493.86
| Professional | | $724.17 | $1,002.31 | $1,493.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.07 / $1,303.29 / $1,711.72
| Professional | | $1,044.07 | $1,303.29 | $1,711.72 |
- 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
- $739.06 / $1,168.27 / $1,706.53
| Professional | | $739.06 | $1,168.27 | $1,706.53 |