- 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
- $1,145.42 / $1,305.21 / $1,912.55
| Professional | | $1,145.42 | $1,305.21 | $1,912.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.59 / $1,528.86 / $2,467.91
| Professional | | $1,104.59 | $1,528.86 | $2,467.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.57 / $2,055.62 / $2,642.38
| Professional | | $1,592.57 | $2,055.62 | $2,642.38 |
- 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
- $1,100.52 / $1,831.61 / $2,799.55
| Professional | | $1,100.52 | $1,831.61 | $2,799.55 |