- 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
- $749.13 / $1,047.44 / $1,221.74
| Professional | | $749.13 | $1,047.44 | $1,221.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.55 / $984.85 / $1,565.14
| Professional | | $711.55 | $984.85 | $1,565.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.89 / $1,312.36 / $1,680.58
| Professional | | $1,025.89 | $1,312.36 | $1,680.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.96 / $1,164.92 / $1,775.47
| Professional | | $587.96 | $1,164.92 | $1,775.47 |