- 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
- $1,012.33 / $1,403.07 / $1,801.27
| Professional | | $1,012.33 | $1,403.07 | $1,801.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.72 / $1,302.04 / $2,282.92
| Professional | | $940.72 | $1,302.04 | $2,282.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.29 / $1,878.74 / $2,232.32
| Professional | | $1,356.29 | $1,878.74 | $2,232.32 |
- 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
- $932.96 / $1,395.30 / $2,372.96
| Professional | | $932.96 | $1,395.30 | $2,372.96 |