- 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
- $1,288.33 / $1,641.24 / $1,951.89
| Professional | | $1,288.33 | $1,641.24 | $1,951.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.33 / $1,708.43 / $2,675.16
| Professional | | $1,234.33 | $1,708.43 | $2,675.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.62 / $2,121.53 / $2,922.76
| Professional | | $1,779.62 | $2,121.53 | $2,922.76 |
- 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
- $1,022.54 / $1,822.92 / $3,034.65
| Professional | | $1,022.54 | $1,822.92 | $3,034.65 |