- 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
- $1,712.00 / $2,417.40 / $2,602.13
| Professional | | $1,712.00 | $2,417.40 | $2,602.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.55 / $2,391.07 / $3,455.52
| Professional | | $1,727.55 | $2,391.07 | $3,455.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.96 / $2,970.31 / $4,218.60
| Professional | | $2,431.96 | $2,970.31 | $4,218.60 |
- 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
- $1,656.61 / $2,924.20 / $4,118.78
| Professional | | $1,656.61 | $2,924.20 | $4,118.78 |