- 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
- $1,757.79 / $2,494.59 / $3,187.19
| Professional | | $1,757.79 | $2,494.59 | $3,187.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.37 / $2,446.19 / $3,243.69
| Professional | | $1,767.37 | $2,446.19 | $3,243.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,548.11 / $3,048.67 / $4,255.70
| Professional | | $2,548.11 | $3,048.67 | $4,255.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $9,165.00 / $19,764.00
| Facility | | $3,713.00 | $9,165.00 | $19,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.12 / $2,949.90 / $4,317.38
| Professional | | $1,832.12 | $2,949.90 | $4,317.38 |