- 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
- $1,286.50 / $1,827.80 / $2,374.71
| Professional | | $1,286.50 | $1,827.80 | $2,374.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.26 / $1,767.84 / $3,358.22
| Professional | | $1,277.26 | $1,767.84 | $3,358.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.83 / $2,430.50 / $2,960.27
| Professional | | $1,767.83 | $2,430.50 | $2,960.27 |
- 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
- $1,110.50 / $1,820.34 / $3,170.84
| Professional | | $1,110.50 | $1,820.34 | $3,170.84 |