- 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
- $1,110.27 / $1,555.26 / $1,790.27
| Professional | | $1,110.27 | $1,555.26 | $1,790.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.86 / $1,458.65 / $2,342.61
| Professional | | $1,053.86 | $1,458.65 | $2,342.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.42 / $1,957.78 / $2,513.73
| Professional | | $1,519.42 | $1,957.78 | $2,513.73 |
- 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
- $934.50 / $1,742.44 / $2,657.41
| Professional | | $934.50 | $1,742.44 | $2,657.41 |