- 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
- $1,028.04 / $1,278.08 / $1,355.30
| Professional | | $1,028.04 | $1,278.08 | $1,355.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.58 / $1,441.86 / $2,190.57
| Professional | | $1,225.58 | $1,441.86 | $2,190.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.65 / $1,450.13 / $2,581.79
| Professional | | $979.65 | $1,450.13 | $2,581.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.80 / $1,135.82 / $1,745.07
| Professional | | $917.80 | $1,135.82 | $1,745.07 |