- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.68 / $1,460.35 / $1,935.44
| Professional | | $1,060.68 | $1,460.35 | $1,935.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.00 / $1,457.43 / $2,273.67
| Professional | | $1,053.00 | $1,457.43 | $2,273.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.43 / $1,926.61 / $2,433.31
| Professional | | $1,457.43 | $1,926.61 | $2,433.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.83 / $1,649.83 / $2,606.87
| Professional | | $1,058.83 | $1,649.83 | $2,606.87 |