- 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
- $855.72 / $934.79 / $944.84
| Professional | | $855.72 | $934.79 | $944.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.75 / $1,010.29 / $1,609.37
| Professional | | $858.75 | $1,010.29 | $1,609.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.77 / $1,002.56 / $1,783.71
| Professional | | $676.77 | $1,002.56 | $1,783.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.97 / $844.70 / $1,335.23
| Professional | | $742.97 | $844.70 | $1,335.23 |