- 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
- $1,057.52 / $1,483.89 / $1,681.48
| Professional | | $1,057.52 | $1,483.89 | $1,681.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.90 / $1,410.25 / $2,166.85
| Professional | | $1,018.90 | $1,410.25 | $2,166.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.02 / $1,897.69 / $2,387.13
| Professional | | $1,469.02 | $1,897.69 | $2,387.13 |
- 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
- $949.14 / $1,480.26 / $2,447.96
| Professional | | $949.14 | $1,480.26 | $2,447.96 |