- 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
- $2,384.96 / $3,377.34 / $3,995.77
| Professional | | $2,384.96 | $3,377.34 | $3,995.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,258.13 / $3,125.44 / $5,089.26
| Professional | | $2,258.13 | $3,125.44 | $5,089.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,255.66 / $4,265.80 / $5,468.71
| Professional | | $3,255.66 | $4,265.80 | $5,468.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.41 / $3,269.05 / $5,025.32
| Professional | | $2,174.41 | $3,269.05 | $5,025.32 |