- 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
- $1,181.27 / $1,663.56 / $1,943.49
| Professional | | $1,181.27 | $1,663.56 | $1,943.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.18 / $1,550.42 / $2,495.17
| Professional | | $1,120.18 | $1,550.42 | $2,495.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.02 / $2,084.28 / $2,686.76
| Professional | | $1,615.02 | $2,084.28 | $2,686.76 |
- 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
- $1,185.48 / $1,686.96 / $2,830.48
| Professional | | $1,185.48 | $1,686.96 | $2,830.48 |