- 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
- $843.81 / $1,182.50 / $1,192.44
| Professional | | $843.81 | $1,182.50 | $1,192.44 |
- 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 / $1,467.14 / $1,902.41
| Professional | | $1,156.17 | $1,467.14 | $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 / $1,296.89 / $1,997.98
| Professional | | $821.06 | $1,296.89 | $1,997.98 |