- 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
- $1,001.53 / $1,419.56 / $1,575.42
| Professional | | $1,001.53 | $1,419.56 | $1,575.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.53 / $1,359.90 / $2,258.09
| Professional | | $982.53 | $1,359.90 | $2,258.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.56 / $1,835.33 / $2,371.50
| Professional | | $1,416.56 | $1,835.33 | $2,371.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.48 / $1,643.84 / $2,539.62
| Professional | | $1,018.48 | $1,643.84 | $2,539.62 |