- 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
- $1,177.65 / $1,657.63 / $1,950.87
| Professional | | $1,177.65 | $1,657.63 | $1,950.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.77 / $1,545.70 / $2,494.76
| Professional | | $1,116.77 | $1,545.70 | $2,494.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.10 / $2,080.78 / $2,679.70
| Professional | | $1,610.10 | $2,080.78 | $2,679.70 |
- 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
- $1,065.47 / $1,609.73 / $2,465.89
| Professional | | $1,065.47 | $1,609.73 | $2,465.89 |