- 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
- $673.86 / $1,085.69 / $1,219.60
| Professional | | $673.86 | $1,085.69 | $1,219.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.83 / $1,036.45 / $1,637.53
| Professional | | $748.83 | $1,036.45 | $1,637.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.64 / $1,244.55 / $1,772.56
| Professional | | $1,079.64 | $1,244.55 | $1,772.56 |
- 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
- $765.30 / $1,228.68 / $1,857.58
| Professional | | $765.30 | $1,228.68 | $1,857.58 |