- 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
- $2,109.62 / $2,994.92 / $3,632.45
| Professional | | $2,109.62 | $2,994.92 | $3,632.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,428.78 / $3,361.64 / $4,446.28
| Professional | | $2,428.78 | $3,361.64 | $4,446.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,501.72 / $3,848.67 / $5,892.08
| Professional | | $3,501.72 | $3,848.67 | $5,892.08 |
- 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
- $2,346.66 / $3,792.56 / $5,764.49
| Professional | | $2,346.66 | $3,792.56 | $5,764.49 |