- 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
- $1,223.58 / $1,369.90 / $1,467.09
| Professional | | $1,223.58 | $1,369.90 | $1,467.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.02 / $1,557.67 / $2,344.61
| Professional | | $1,324.02 | $1,557.67 | $2,344.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.68 / $1,574.48 / $2,804.45
| Professional | | $1,063.68 | $1,574.48 | $2,804.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.00 / $1,300.31 / $1,911.49
| Professional | | $1,115.00 | $1,300.31 | $1,911.49 |