- 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
- $1,036.20 / $1,411.52 / $1,903.07
| Professional | | $1,036.20 | $1,411.52 | $1,903.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.60 / $1,423.68 / $2,521.40
| Professional | | $1,028.60 | $1,423.68 | $2,521.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.67 / $1,861.56 / $2,376.21
| Professional | | $1,423.67 | $1,861.56 | $2,376.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.81 / $1,611.46 / $2,670.34
| Professional | | $944.81 | $1,611.46 | $2,670.34 |