- 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
- $2,532.64 / $3,596.48 / $4,228.29
| Professional | | $2,532.64 | $3,596.48 | $4,228.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.73 / $3,315.88 / $5,455.21
| Professional | | $2,395.73 | $3,315.88 | $5,455.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.03 / $4,517.95 / $5,842.94
| Professional | | $3,454.03 | $4,517.95 | $5,842.94 |
- 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
- $2,452.27 / $4,050.12 / $6,188.29
| Professional | | $2,452.27 | $4,050.12 | $6,188.29 |