- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,162.28 / $7,762.47
| Facility | | $1,698.24 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,630.78 / $3,890.45
| Professional | | $3,235.94 | $3,630.78 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,951.21 / $6,918.31
| Professional | | $2,818.38 | $2,951.21 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $6,760.83 / $26,302.68
| Facility | | $1,023.29 | $6,760.83 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,786.30 / $9,332.54
| Professional | | $3,162.28 | $4,786.30 | $9,332.54 |