- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.51 / $888.66 / $1,049.30
| Professional | | $630.51 | $888.66 | $1,049.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.88 / $1,088.40 / $1,088.40
| Professional | | $761.88 | $1,088.40 | $1,088.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.94 / $984.03 / $2,261.28
| Professional | | $708.94 | $984.03 | $2,261.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $8,699.00 / $12,680.00
| Facility | | $3,599.00 | $8,699.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.58 / $1,000.00 / $1,286.23
| Professional | | $787.58 | $1,000.00 | $1,286.23 |