- 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
- $1,386.35 / $1,764.88 / $2,220.31
| Professional | | $1,386.35 | $1,764.88 | $2,220.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.12 / $1,842.38 / $2,899.03
| Professional | | $1,331.12 | $1,842.38 | $2,899.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.73 / $2,285.69 / $3,138.58
| Professional | | $1,887.73 | $2,285.69 | $3,138.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.98 / $1,970.43 / $3,288.61
| Professional | | $1,303.98 | $1,970.43 | $3,288.61 |