- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $3,467.37
| Facility | | $1,513.56 | $1,995.26 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $3,715.35
| Professional | | $2,398.83 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,801.89 / $4,677.35
| Professional | | $2,041.74 | $3,801.89 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $14,454.40
| Facility | | $2,187.76 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $5,011.87
| Professional | | $2,454.71 | $3,090.30 | $5,011.87 |