- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.17 / $1,458.01 / $2,193.77
| Professional | | $1,140.17 | $1,458.01 | $2,193.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.64 / $1,607.81 / $2,603.09
| Professional | | $1,161.64 | $1,607.81 | $2,603.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.81 / $2,036.15 / $2,693.53
| Professional | | $1,607.81 | $2,036.15 | $2,693.53 |
- 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
- $1,160.06 / $1,824.13 / $2,885.06
| Professional | | $1,160.06 | $1,824.13 | $2,885.06 |