- 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
- $1,670.15 / $2,316.17 / $3,026.38
| Professional | | $1,670.15 | $2,316.17 | $3,026.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.33 / $2,138.87 / $3,946.64
| Professional | | $1,545.33 | $2,138.87 | $3,946.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,227.98 / $3,177.73 / $3,726.84
| Professional | | $2,227.98 | $3,177.73 | $3,726.84 |
- 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
- $1,646.48 / $2,583.32 / $3,978.92
| Professional | | $1,646.48 | $2,583.32 | $3,978.92 |