- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.39 / $2,993.72 / $3,955.04
| Facility | | $1,540.39 | $2,993.72 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.70 / $1,633.52 / $1,977.96
| Professional | | $1,224.70 | $1,633.52 | $1,977.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.04 / $1,649.88 / $2,433.94
| Professional | | $1,192.04 | $1,649.88 | $2,433.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.62 / $2,047.81 / $2,788.81
| Professional | | $1,718.62 | $2,047.81 | $2,788.81 |
- 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
- $1,131.49 / $1,933.11 / $2,982.00
| Professional | | $1,131.49 | $1,933.11 | $2,982.00 |