- 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
- $1,258.42 / $1,408.81 / $1,548.29
| Professional | | $1,258.42 | $1,408.81 | $1,548.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.48 / $1,637.03 / $2,393.38
| Professional | | $1,391.48 | $1,637.03 | $2,393.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.10 / $1,667.87 / $2,976.62
| Professional | | $1,123.10 | $1,667.87 | $2,976.62 |
- 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
- $889.58 / $1,263.67 / $1,965.71
| Professional | | $889.58 | $1,263.67 | $1,965.71 |