- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,761.36 / $4,026.21
| Facility | | $3,438.26 | $3,761.36 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.63 / $1,337.36 / $1,499.23
| Professional | | $860.63 | $1,337.36 | $1,499.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.80 / $1,257.85 / $1,795.83
| Professional | | $908.80 | $1,257.85 | $1,795.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.28 / $1,573.55 / $2,151.84
| Professional | | $1,310.28 | $1,573.55 | $2,151.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.59 / $1,491.58 / $2,146.13
| Professional | | $855.59 | $1,491.58 | $2,146.13 |