- 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
- $1,013.44 / $1,424.28 / $1,667.80
| Professional | | $1,013.44 | $1,424.28 | $1,667.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.51 / $1,330.81 / $2,130.33
| Professional | | $961.51 | $1,330.81 | $2,130.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.27 / $1,786.15 / $2,296.92
| Professional | | $1,386.27 | $1,786.15 | $2,296.92 |
- 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
- $990.51 / $1,592.15 / $2,416.60
| Professional | | $990.51 | $1,592.15 | $2,416.60 |