- 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
- $1,253.63 / $1,365.67 / $1,540.35
| Professional | | $1,253.63 | $1,365.67 | $1,540.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.83 / $1,628.03 / $2,341.83
| Professional | | $1,383.83 | $1,628.03 | $2,341.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.76 / $1,660.21 / $2,962.03
| Professional | | $1,122.76 | $1,660.21 | $2,962.03 |
- 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
- $944.69 / $1,326.81 / $1,955.30
| Professional | | $944.69 | $1,326.81 | $1,955.30 |