- 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
- $1,156.07 / $1,614.92 / $1,913.25
| Professional | | $1,156.07 | $1,614.92 | $1,913.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.72 / $1,553.94 / $2,409.03
| Professional | | $1,122.72 | $1,553.94 | $2,409.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.69 / $1,986.91 / $2,657.73
| Professional | | $1,618.69 | $1,986.91 | $2,657.73 |
- 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
- $1,147.79 / $1,842.25 / $2,732.76
| Professional | | $1,147.79 | $1,842.25 | $2,732.76 |