- 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
- $1,065.25 / $1,502.52 / $1,766.15
| Professional | | $1,065.25 | $1,502.52 | $1,766.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.77 / $1,397.60 / $2,262.17
| Professional | | $1,009.77 | $1,397.60 | $2,262.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.83 / $1,899.92 / $2,429.46
| Professional | | $1,455.83 | $1,899.92 | $2,429.46 |
- 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
- $1,069.58 / $1,684.03 / $2,566.17
| Professional | | $1,069.58 | $1,684.03 | $2,566.17 |