- 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
- $545.78 / $780.81 / $1,079.24
| Professional | | $545.78 | $780.81 | $1,079.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.29 / $869.60 / $1,148.64
| Professional | | $628.29 | $869.60 | $1,148.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.83 / $1,048.36 / $1,484.28
| Professional | | $905.83 | $1,048.36 | $1,484.28 |
- 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
- $557.96 / $972.01 / $1,360.38
| Professional | | $557.96 | $972.01 | $1,360.38 |