- 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
- $1,167.13 / $1,636.48 / $1,926.45
| Professional | | $1,167.13 | $1,636.48 | $1,926.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.68 / $1,533.12 / $2,456.61
| Professional | | $1,107.68 | $1,533.12 | $2,456.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.99 / $2,052.62 / $2,642.37
| Professional | | $1,596.99 | $2,052.62 | $2,642.37 |
- 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
- $1,139.80 / $1,831.59 / $2,786.74
| Professional | | $1,139.80 | $1,831.59 | $2,786.74 |