- 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
- $1,018.20 / $1,429.47 / $1,676.10
| Professional | | $1,018.20 | $1,429.47 | $1,676.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.26 / $1,337.39 / $2,136.88
| Professional | | $966.26 | $1,337.39 | $2,136.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,792.15 / $2,303.71
| Professional | | $1,393.12 | $1,792.15 | $2,303.71 |
- 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
- $993.63 / $1,596.86 / $2,424.03
| Professional | | $993.63 | $1,596.86 | $2,424.03 |