- 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 / $2,818.38 / $4,073.80
| Professional | | $2,454.71 | $2,818.38 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,073.80 / $4,897.79
| Professional | | $2,089.30 | $4,073.80 | $4,897.79 |
- 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
- $2,398.83 / $3,090.30 / $5,128.61
| Professional | | $2,398.83 | $3,090.30 | $5,128.61 |