- 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
- $1,150.14 / $1,416.40 / $1,426.59
| Professional | | $1,150.14 | $1,416.40 | $1,426.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.40 / $1,494.59 / $2,385.26
| Professional | | $1,270.40 | $1,494.59 | $2,385.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.26 / $1,648.55 / $2,717.92
| Professional | | $1,043.26 | $1,648.55 | $2,717.92 |
- 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
- $897.83 / $1,256.09 / $1,866.27
| Professional | | $897.83 | $1,256.09 | $1,866.27 |