- 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
- $1,117.08 / $1,568.25 / $1,810.86
| Professional | | $1,117.08 | $1,568.25 | $1,810.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.03 / $1,467.17 / $2,351.96
| Professional | | $1,060.03 | $1,467.17 | $2,351.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.30 / $1,949.64 / $2,529.08
| Professional | | $1,528.30 | $1,949.64 | $2,529.08 |
- 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
- $1,005.58 / $1,753.07 / $2,668.03
| Professional | | $1,005.58 | $1,753.07 | $2,668.03 |