- 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
- $1,505.90 / $2,151.77 / $2,628.33
| Professional | | $1,505.90 | $2,151.77 | $2,628.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.33 / $1,972.78 / $3,439.32
| Professional | | $1,425.33 | $1,972.78 | $3,439.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.96 / $2,912.49 / $3,626.76
| Professional | | $2,054.96 | $2,912.49 | $3,626.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.75 / $2,513.94 / $3,863.98
| Professional | | $1,526.75 | $2,513.94 | $3,863.98 |