- 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
- $1,222.26 / $1,634.12 / $2,004.82
| Professional | | $1,222.26 | $1,634.12 | $2,004.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.91 / $1,604.02 / $2,643.62
| Professional | | $1,158.91 | $1,604.02 | $2,643.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.24 / $2,000.05 / $2,783.96
| Professional | | $1,065.24 | $2,000.05 | $2,783.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $8,699.00 / $14,986.22
| Facility | | $3,219.00 | $8,699.00 | $14,986.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.12 / $1,890.35 / $2,970.36
| Professional | | $750.12 | $1,890.35 | $2,970.36 |