- 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
- $1,402.74 / $2,004.41 / $2,293.44
| Professional | | $1,402.74 | $2,004.41 | $2,293.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.80 / $1,883.46 / $3,059.93
| Professional | | $1,360.80 | $1,883.46 | $3,059.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.94 / $2,573.71 / $3,293.96
| Professional | | $1,961.94 | $2,573.71 | $3,293.96 |
- 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
- $1,415.58 / $2,283.26 / $3,523.07
| Professional | | $1,415.58 | $2,283.26 | $3,523.07 |