- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,311.31
| Facility | | $1,698.24 | $2,511.89 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,754.23 / $3,715.35
| Professional | | $2,454.71 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,981.07 / $4,786.30
| Professional | | $2,290.87 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $22,908.68
| Facility | | $3,715.35 | $7,762.47 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,011.87
| Professional | | $2,290.87 | $3,162.28 | $5,011.87 |