- 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
- $1,399.27 / $2,169.26 / $2,387.26
| Professional | | $1,399.27 | $2,169.26 | $2,387.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.08 / $2,015.33 / $2,962.39
| Professional | | $1,456.08 | $2,015.33 | $2,962.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.30 / $2,605.02 / $3,538.31
| Professional | | $2,099.30 | $2,605.02 | $3,538.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.02 / $2,452.64 / $3,466.69
| Professional | | $1,485.02 | $2,452.64 | $3,466.69 |