- 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
- $1,140.32 / $1,258.59 / $2,788.49
| Professional | | $1,140.32 | $1,258.59 | $2,788.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.08 / $1,302.45 / $1,978.01
| Professional | | $1,107.08 | $1,302.45 | $1,978.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.05 / $1,475.15 / $8,661.60
| Professional | | $882.05 | $1,475.15 | $8,661.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.58 / $1,229.28 / $2,965.78
| Professional | | $1,118.58 | $1,229.28 | $2,965.78 |