- 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
- $1,208.38 / $1,716.89 / $1,995.68
| Professional | | $1,208.38 | $1,716.89 | $1,995.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.45 / $1,698.89 / $2,615.57
| Professional | | $1,227.45 | $1,698.89 | $2,615.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.23 / $2,098.39 / $2,760.90
| Professional | | $1,323.23 | $2,098.39 | $2,760.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.07 / $1,806.14 / $2,940.92
| Professional | | $973.07 | $1,806.14 | $2,940.92 |