- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.74 / $1,642.36 / $1,920.37
| Professional | | $1,170.74 | $1,642.36 | $1,920.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.16 / $1,537.94 / $2,462.75
| Professional | | $1,111.16 | $1,537.94 | $2,462.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.02 / $2,041.26 / $2,650.29
| Professional | | $1,602.02 | $2,041.26 | $2,650.29 |
- 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
- $1,019.93 / $1,837.09 / $2,793.70
| Professional | | $1,019.93 | $1,837.09 | $2,793.70 |