- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $4,466.84
| Professional | | $1,412.54 | $1,737.80 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $2,818.38
| Professional | | $1,513.56 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,548.13
| Professional | | $1,905.46 | $2,570.40 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,715.35
| Professional | | $1,479.11 | $2,089.30 | $3,715.35 |