- 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
- $1,512.32 / $2,052.34 / $2,506.71
| Professional | | $1,512.32 | $2,052.34 | $2,506.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.15 / $1,928.24 / $3,368.16
| Professional | | $1,393.15 | $1,928.24 | $3,368.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.59 / $2,773.14 / $3,362.82
| Professional | | $2,008.59 | $2,773.14 | $3,362.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.71 / $2,330.98 / $3,596.71
| Professional | | $1,424.71 | $2,330.98 | $3,596.71 |