- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.68 / $2,203.57 / $3,216.15
| Professional | | $1,697.68 | $2,203.57 | $3,216.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.89 / $2,046.91 / $3,574.32
| Professional | | $1,478.89 | $2,046.91 | $3,574.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.60 / $2,894.33 / $4,210.68
| Professional | | $1,980.60 | $2,894.33 | $4,210.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.31 / $2,918.71 / $4,063.45
| Professional | | $1,381.31 | $2,918.71 | $4,063.45 |