- 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
- $794.02 / $1,316.51 / $1,331.65
| Professional | | $794.02 | $1,316.51 | $1,331.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.83 / $1,246.82 / $1,764.23
| Professional | | $900.83 | $1,246.82 | $1,764.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.78 / $1,580.14 / $2,145.17
| Professional | | $1,298.78 | $1,580.14 | $2,145.17 |
- 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
- $925.46 / $1,399.26 / $2,131.69
| Professional | | $925.46 | $1,399.26 | $2,131.69 |