- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.71 / $2,385.50 / $2,817.07
| Professional | | $1,639.71 | $2,385.50 | $2,817.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.94 / $2,174.30 / $3,483.13
| Professional | | $1,570.94 | $2,174.30 | $3,483.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.89 / $2,919.86 / $3,752.69
| Professional | | $2,264.89 | $2,919.86 | $3,752.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.19 / $2,526.11 / $3,951.19
| Professional | | $1,654.19 | $2,526.11 | $3,951.19 |