- 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
- $1,244.05 / $1,696.46 / $1,978.64
| Professional | | $1,244.05 | $1,696.46 | $1,978.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.23 / $1,594.78 / $2,584.01
| Professional | | $1,152.23 | $1,594.78 | $2,584.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.22 / $2,182.76 / $2,839.53
| Professional | | $1,661.22 | $2,182.76 | $2,839.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.00 / $5,979.00 / $12,680.00
| Facility | | $2,609.00 | $5,979.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.42 / $1,968.27 / $2,931.26
| Professional | | $993.42 | $1,968.27 | $2,931.26 |