- 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
- $1,333.18 / $1,848.76 / $2,222.57
| Professional | | $1,333.18 | $1,848.76 | $2,222.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.49 / $1,748.78 / $2,838.31
| Professional | | $1,263.49 | $1,748.78 | $2,838.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.64 / $2,264.62 / $3,045.62
| Professional | | $1,578.64 | $2,264.62 | $3,045.62 |
- 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
- $1,045.76 / $1,859.13 / $3,219.72
| Professional | | $1,045.76 | $1,859.13 | $3,219.72 |