- 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
- $1,068.05 / $2,056.71 / $2,167.03
| Professional | | $1,068.05 | $2,056.71 | $2,167.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.59 / $2,266.58 / $3,204.47
| Professional | | $1,926.59 | $2,266.58 | $3,204.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.31 / $2,694.72 / $4,782.52
| Professional | | $1,475.31 | $2,694.72 | $4,782.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.90 / $2,486.86 / $3,914.99
| Professional | | $1,748.90 | $2,486.86 | $3,914.99 |