- 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
- $1,006.57 / $1,410.92 / $1,663.93
| Professional | | $1,006.57 | $1,410.92 | $1,663.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.32 / $1,322.23 / $2,121.67
| Professional | | $955.32 | $1,322.23 | $2,121.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.32 / $1,777.91 / $2,278.13
| Professional | | $1,377.32 | $1,777.91 | $2,278.13 |
- 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
- $982.63 / $1,579.12 / $2,406.79
| Professional | | $982.63 | $1,579.12 | $2,406.79 |