- 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
- $865.55 / $1,231.77 / $1,413.31
| Professional | | $865.55 | $1,231.77 | $1,413.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.31 / $1,153.38 / $1,806.78
| Professional | | $833.31 | $1,153.38 | $1,806.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.44 / $1,516.15 / $1,969.02
| Professional | | $1,201.44 | $1,516.15 | $1,969.02 |
- 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
- $782.90 / $1,199.31 / $1,790.95
| Professional | | $782.90 | $1,199.31 | $1,790.95 |