- 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
- $1,082.69 / $1,469.94 / $1,803.86
| Professional | | $1,082.69 | $1,469.94 | $1,803.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.64 / $1,438.94 / $2,288.33
| Professional | | $1,039.64 | $1,438.94 | $2,288.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.32 / $1,872.44 / $2,461.35
| Professional | | $1,448.32 | $1,872.44 | $2,461.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.66 / $1,706.13 / $2,595.83
| Professional | | $978.66 | $1,706.13 | $2,595.83 |