- 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
- $2,272.30 / $3,145.79 / $3,793.94
| Professional | | $2,272.30 | $3,145.79 | $3,793.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.02 / $2,975.80 / $4,852.13
| Professional | | $2,150.02 | $2,975.80 | $4,852.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.42 / $3,842.05 / $5,236.55
| Professional | | $2,214.42 | $3,842.05 | $5,236.55 |
- 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
- $1,625.01 / $3,537.38 / $5,504.16
| Professional | | $1,625.01 | $3,537.38 | $5,504.16 |