- 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
- $1,261.67 / $1,774.33 / $1,903.45
| Professional | | $1,261.67 | $1,774.33 | $1,903.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.11 / $1,652.77 / $2,610.69
| Professional | | $1,194.11 | $1,652.77 | $2,610.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.64 / $2,261.60 / $2,841.65
| Professional | | $1,721.64 | $2,261.60 | $2,841.65 |
- 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
- $1,255.41 / $1,952.61 / $2,961.52
| Professional | | $1,255.41 | $1,952.61 | $2,961.52 |