- 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
- $797.09 / $1,124.77 / $1,294.59
| Professional | | $797.09 | $1,124.77 | $1,294.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.85 / $1,046.16 / $1,676.41
| Professional | | $755.85 | $1,046.16 | $1,676.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.75 / $1,578.46 / $1,815.51
| Professional | | $1,089.75 | $1,578.46 | $1,815.51 |
- 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
- $801.50 / $1,263.32 / $1,901.69
| Professional | | $801.50 | $1,263.32 | $1,901.69 |