- 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
- $1,212.54 / $1,355.77 / $1,494.23
| Professional | | $1,212.54 | $1,355.77 | $1,494.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.03 / $1,580.03 / $2,315.73
| Professional | | $1,343.03 | $1,580.03 | $2,315.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.59 / $1,611.97 / $2,873.72
| Professional | | $1,086.59 | $1,611.97 | $2,873.72 |
- 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
- $915.06 / $1,285.22 / $1,894.00
| Professional | | $915.06 | $1,285.22 | $1,894.00 |