- 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
- $839.07 / $1,182.50 / $1,381.20
| Professional | | $839.07 | $1,182.50 | $1,381.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.92 / $1,109.93 / $1,761.30
| Professional | | $801.92 | $1,109.93 | $1,761.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.17 / $1,472.43 / $1,902.41
| Professional | | $1,156.17 | $1,472.43 | $1,902.41 |
- 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
- $821.06 / $1,318.69 / $2,031.21
| Professional | | $821.06 | $1,318.69 | $2,031.21 |