- 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
- $1,156.39 / $1,628.85 / $1,903.92
| Professional | | $1,156.39 | $1,628.85 | $1,903.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.44 / $1,517.56 / $2,434.89
| Professional | | $1,096.44 | $1,517.56 | $2,434.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.79 / $2,041.42 / $2,632.91
| Professional | | $1,580.79 | $2,041.42 | $2,632.91 |
- 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
- $1,134.85 / $1,825.05 / $2,809.10
| Professional | | $1,134.85 | $1,825.05 | $2,809.10 |