- 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
- $1,293.41 / $1,405.52 / $2,237.25
| Professional | | $1,293.41 | $1,405.52 | $2,237.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.73 / $1,708.96 / $2,866.33
| Professional | | $1,234.73 | $1,708.96 | $2,866.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.08 / $2,389.60 / $2,954.20
| Professional | | $1,774.08 | $2,389.60 | $2,954.20 |
- 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
- $1,263.74 / $2,008.47 / $3,149.35
| Professional | | $1,263.74 | $2,008.47 | $3,149.35 |