- 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
- $1,992.76 / $2,766.20 / $3,116.82
| Professional | | $1,992.76 | $2,766.20 | $3,116.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.87 / $2,553.46 / $4,346.27
| Professional | | $1,844.87 | $2,553.46 | $4,346.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.85 / $3,741.88 / $4,449.68
| Professional | | $2,659.85 | $3,741.88 | $4,449.68 |
- 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
- $1,712.41 / $3,015.24 / $4,749.64
| Professional | | $1,712.41 | $3,015.24 | $4,749.64 |