- 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
- $1,079.68 / $1,517.75 / $1,762.96
| Professional | | $1,079.68 | $1,517.75 | $1,762.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.31 / $1,417.73 / $2,263.84
| Professional | | $1,024.31 | $1,417.73 | $2,263.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.80 / $1,900.01 / $2,449.21
| Professional | | $1,476.80 | $1,900.01 | $2,449.21 |
- 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
- $1,056.16 / $1,697.71 / $2,568.05
| Professional | | $1,056.16 | $1,697.71 | $2,568.05 |