- 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
- $1,426.30 / $2,025.36 / $2,394.61
| Professional | | $1,426.30 | $2,025.36 | $2,394.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.69 / $1,881.92 / $3,056.66
| Professional | | $1,359.69 | $1,881.92 | $3,056.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.93 / $2,508.60 / $3,280.35
| Professional | | $1,850.93 | $2,508.60 | $3,280.35 |
- 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
- $1,332.43 / $2,273.82 / $3,467.41
| Professional | | $1,332.43 | $2,273.82 | $3,467.41 |