- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $3,548.13
| Professional | | $1,202.26 | $1,412.54 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,445.44 / $2,344.23
| Professional | | $1,288.25 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,754.23
| Professional | | $1,318.26 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,548.82 / $2,951.21
| Professional | | $1,023.29 | $1,548.82 | $2,951.21 |