- 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
- $2,424.82 / $3,512.51 / $4,051.40
| Professional | | $2,424.82 | $3,512.51 | $4,051.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,394.77 / $3,314.57 / $5,058.85
| Professional | | $2,394.77 | $3,314.57 | $5,058.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.68 / $4,395.37 / $5,785.81
| Professional | | $3,452.68 | $4,395.37 | $5,785.81 |
- 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
- $2,482.32 / $3,613.50 / $5,738.66
| Professional | | $2,482.32 | $3,613.50 | $5,738.66 |