- 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
- $677.44 / $983.13 / $1,104.64
| Professional | | $677.44 | $983.13 | $1,104.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.82 / $1,159.79 / $1,663.12
| Professional | | $985.82 | $1,159.79 | $1,663.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.19 / $1,196.64 / $2,130.34
| Professional | | $795.19 | $1,196.64 | $2,130.34 |
- 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
- $753.90 / $942.30 / $1,368.43
| Professional | | $753.90 | $942.30 | $1,368.43 |