- 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
- $1,303.43 / $1,543.19 / $2,054.85
| Professional | | $1,303.43 | $1,543.19 | $2,054.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.38 / $1,885.65 / $2,916.06
| Professional | | $1,362.38 | $1,885.65 | $2,916.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.66 / $2,107.91 / $3,117.47
| Professional | | $1,885.66 | $2,107.91 | $3,117.47 |
- 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
- $1,262.58 / $1,960.58 / $3,329.82
| Professional | | $1,262.58 | $1,960.58 | $3,329.82 |