- 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
- $1,271.38 / $1,791.51 / $2,109.42
| Professional | | $1,271.38 | $1,791.51 | $2,109.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.09 / $1,667.96 / $2,691.89
| Professional | | $1,205.09 | $1,667.96 | $2,691.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.46 / $2,242.28 / $2,897.09
| Professional | | $1,737.46 | $2,242.28 | $2,897.09 |
- 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
- $1,200.18 / $2,008.16 / $3,053.63
| Professional | | $1,200.18 | $2,008.16 | $3,053.63 |