- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.11 / $2,054.42 / $2,203.37
| Professional | | $1,379.11 | $2,054.42 | $2,203.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.21 / $1,903.40 / $3,110.81
| Professional | | $1,375.21 | $1,903.40 | $3,110.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.71 / $2,528.46 / $3,331.92
| Professional | | $1,982.71 | $2,528.46 | $3,331.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,505.00 / $7,819.00 / $19,195.00
| Facility | | $4,505.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.10 / $2,078.12 / $3,528.84
| Professional | | $1,348.10 | $2,078.12 | $3,528.84 |