- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.58 / $1,448.02 / $1,675.57
| Professional | | $1,029.58 | $1,448.02 | $1,675.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.62 / $1,351.73 / $2,166.94
| Professional | | $976.62 | $1,351.73 | $2,166.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.05 / $2,024.13 / $2,336.00
| Professional | | $1,408.05 | $2,024.13 | $2,336.00 |
- 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
- $1,023.87 / $1,619.24 / $2,458.14
| Professional | | $1,023.87 | $1,619.24 | $2,458.14 |