- 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
- $890.78 / $1,242.40 / $1,417.03
| Professional | | $890.78 | $1,242.40 | $1,417.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.08 / $1,234.72 / $1,820.75
| Professional | | $892.08 | $1,234.72 | $1,820.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.16 / $1,575.67 / $2,022.68
| Professional | | $1,286.16 | $1,575.67 | $2,022.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.33 / $1,276.72 / $2,108.87
| Professional | | $817.33 | $1,276.72 | $2,108.87 |