- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.17 / $1,550.00 / $1,976.61
| Professional | | $1,131.17 | $1,550.00 | $1,976.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,449.04 / $2,525.57
| Professional | | $1,046.93 | $1,449.04 | $2,525.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.42 / $2,099.67 / $2,632.89
| Professional | | $1,509.42 | $2,099.67 | $2,632.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.85 / $1,793.02 / $2,813.71
| Professional | | $1,046.85 | $1,793.02 | $2,813.71 |