- 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
- $1,328.65 / $1,872.13 / $2,193.11
| Professional | | $1,328.65 | $1,872.13 | $2,193.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.29 / $1,742.96 / $2,822.95
| Professional | | $1,259.29 | $1,742.96 | $2,822.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.58 / $2,368.46 / $3,032.11
| Professional | | $1,815.58 | $2,368.46 | $3,032.11 |
- 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
- $1,283.01 / $2,101.75 / $3,202.30
| Professional | | $1,283.01 | $2,101.75 | $3,202.30 |