- 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
- $1,402.38 / $1,975.26 / $2,337.41
| Professional | | $1,402.38 | $1,975.26 | $2,337.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.23 / $1,839.76 / $2,980.98
| Professional | | $1,329.23 | $1,839.76 | $2,980.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.41 / $2,500.46 / $3,199.50
| Professional | | $1,916.41 | $2,500.46 | $3,199.50 |
- 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
- $1,231.29 / $1,995.53 / $3,381.57
| Professional | | $1,231.29 | $1,995.53 | $3,381.57 |