- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.58 / $2,559.23 / $2,664.36
| Professional | | $1,813.58 | $2,559.23 | $2,664.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,379.94 / $2,799.93 / $4,430.43
| Professional | | $2,379.94 | $2,799.93 | $4,430.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.83 / $3,055.23 / $5,620.68
| Professional | | $2,547.83 | $3,055.23 | $5,620.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,267.87 / $3,505.62 / $5,125.87
| Professional | | $2,267.87 | $3,505.62 | $5,125.87 |