- 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
- $1,535.66 / $2,182.37 / $2,540.98
| Professional | | $1,535.66 | $2,182.37 | $2,540.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.68 / $2,025.86 / $3,295.15
| Professional | | $1,463.68 | $2,025.86 | $3,295.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.28 / $2,760.55 / $3,536.46
| Professional | | $2,110.28 | $2,760.55 | $3,536.46 |
- 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
- $1,237.25 / $2,205.69 / $3,737.95
| Professional | | $1,237.25 | $2,205.69 | $3,737.95 |