- 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
- $1,016.60 / $1,389.67 / $1,688.47
| Professional | | $1,016.60 | $1,389.67 | $1,688.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.68 / $1,362.88 / $2,049.21
| Professional | | $984.68 | $1,362.88 | $2,049.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.95 / $1,704.68 / $2,306.92
| Professional | | $1,351.95 | $1,704.68 | $2,306.92 |
- 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
- $935.62 / $1,565.17 / $2,456.82
| Professional | | $935.62 | $1,565.17 | $2,456.82 |