- 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
- $2,503.04 / $3,692.52 / $5,094.55
| Professional | | $2,503.04 | $3,692.52 | $5,094.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,912.01 / $4,030.46 / $5,353.01
| Professional | | $2,912.01 | $4,030.46 | $5,353.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,198.39 / $4,624.89 / $7,028.12
| Professional | | $4,198.39 | $4,624.89 | $7,028.12 |
- 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
- $2,913.59 / $4,305.24 / $6,419.67
| Professional | | $2,913.59 | $4,305.24 | $6,419.67 |