- 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
- $877.73 / $1,226.24 / $1,427.46
| Professional | | $877.73 | $1,226.24 | $1,427.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.06 / $1,154.41 / $1,829.43
| Professional | | $834.06 | $1,154.41 | $1,829.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.52 / $1,599.58 / $1,973.96
| Professional | | $1,202.52 | $1,599.58 | $1,973.96 |
- 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
- $856.07 / $1,368.28 / $2,108.11
| Professional | | $856.07 | $1,368.28 | $2,108.11 |