- 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
- $1,135.68 / $1,599.61 / $1,850.34
| Professional | | $1,135.68 | $1,599.61 | $1,850.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.79 / $1,490.36 / $2,406.92
| Professional | | $1,076.79 | $1,490.36 | $2,406.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.80 / $2,002.20 / $2,587.13
| Professional | | $1,462.80 | $2,002.20 | $2,587.13 |
- 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
- $1,058.31 / $1,613.59 / $2,730.38
| Professional | | $1,058.31 | $1,613.59 | $2,730.38 |