- 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
- $1,099.48 / $1,674.21 / $1,821.66
| Professional | | $1,099.48 | $1,674.21 | $1,821.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.94 / $1,568.08 / $2,342.01
| Professional | | $1,132.94 | $1,568.08 | $2,342.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.41 / $1,999.90 / $2,509.27
| Professional | | $1,633.41 | $1,999.90 | $2,509.27 |
- 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
- $1,053.13 / $1,518.22 / $2,656.73
| Professional | | $1,053.13 | $1,518.22 | $2,656.73 |