- 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
- $1,251.03 / $1,756.76 / $2,067.44
| Professional | | $1,251.03 | $1,756.76 | $2,067.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.86 / $1,642.73 / $2,639.48
| Professional | | $1,186.86 | $1,642.73 | $2,639.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.18 / $2,205.54 / $2,838.53
| Professional | | $1,711.18 | $2,205.54 | $2,838.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.19 / $1,967.57 / $2,994.17
| Professional | | $1,253.19 | $1,967.57 | $2,994.17 |