- 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
- $1,210.79 / $1,686.16 / $2,344.50
| Professional | | $1,210.79 | $1,686.16 | $2,344.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.69 / $1,704.76 / $2,989.35
| Professional | | $1,231.69 | $1,704.76 | $2,989.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.77 / $2,216.16 / $2,874.96
| Professional | | $1,704.77 | $2,216.16 | $2,874.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $9,064.00 / $14,986.22
| Facility | | $3,713.00 | $9,064.00 | $14,986.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.34 / $1,801.55 / $3,073.93
| Professional | | $1,186.34 | $1,801.55 | $3,073.93 |