- 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
- $1,601.87 / $2,197.46 / $2,666.47
| Professional | | $1,601.87 | $2,197.46 | $2,666.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.31 / $2,100.08 / $3,422.07
| Professional | | $1,517.31 | $2,100.08 | $3,422.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,585.51 / $2,687.95 / $3,666.59
| Professional | | $1,585.51 | $2,687.95 | $3,666.59 |
- 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
- $1,107.95 / $2,541.55 / $3,881.93
| Professional | | $1,107.95 | $2,541.55 | $3,881.93 |