- 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
- $819.35 / $1,146.01 / $1,338.92
| Professional | | $819.35 | $1,146.01 | $1,338.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.03 / $1,078.25 / $1,706.51
| Professional | | $779.03 | $1,078.25 | $1,706.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.18 / $1,424.38 / $1,846.05
| Professional | | $1,123.18 | $1,424.38 | $1,846.05 |
- 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
- $815.57 / $1,279.61 / $1,935.82
| Professional | | $815.57 | $1,279.61 | $1,935.82 |