- 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
- $1,063.47 / $1,493.83 / $1,743.05
| Professional | | $1,063.47 | $1,493.83 | $1,743.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.87 / $1,396.37 / $2,239.09
| Professional | | $1,008.87 | $1,396.37 | $2,239.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.56 / $2,082.94 / $2,412.01
| Professional | | $1,454.56 | $2,082.94 | $2,412.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $9,064.00 / $14,986.22
| Facility | | $3,713.00 | $9,064.00 | $14,986.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.61 / $1,642.96 / $2,568.90
| Professional | | $1,065.61 | $1,642.96 | $2,568.90 |