- 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
- $1,515.93 / $2,137.08 / $2,474.54
| Professional | | $1,515.93 | $2,137.08 | $2,474.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.91 / $1,988.80 / $3,218.09
| Professional | | $1,436.91 | $1,988.80 | $3,218.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.67 / $2,698.56 / $3,457.05
| Professional | | $2,071.67 | $2,698.56 | $3,457.05 |
- 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
- $1,489.76 / $2,396.32 / $3,650.56
| Professional | | $1,489.76 | $2,396.32 | $3,650.56 |