- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.61 / $1,676.06 / $1,754.55
| Professional | | $1,484.61 | $1,676.06 | $1,754.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.86 / $1,863.37 / $2,853.53
| Professional | | $1,583.86 | $1,863.37 | $2,853.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.52 / $1,878.09 / $3,339.41
| Professional | | $1,268.52 | $1,878.09 | $3,339.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.16 / $1,568.45 / $2,310.52
| Professional | | $1,132.16 | $1,568.45 | $2,310.52 |