- 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
- $1,025.79 / $1,454.68 / $1,719.25
| Professional | | $1,025.79 | $1,454.68 | $1,719.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.53 / $1,343.29 / $2,190.59
| Professional | | $970.53 | $1,343.29 | $2,190.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.26 / $1,858.06 / $2,338.55
| Professional | | $1,399.26 | $1,858.06 | $2,338.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.48 / $1,621.00 / $2,484.96
| Professional | | $981.48 | $1,621.00 | $2,484.96 |