- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $3,801.89
| Facility | | $1,513.56 | $1,995.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $3,981.07
| Professional | | $2,344.23 | $2,630.27 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,073.80 / $4,570.88
| Professional | | $2,137.96 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $11,748.98
| Facility | | $1,548.82 | $4,073.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $4,786.30
| Professional | | $2,344.23 | $3,090.30 | $4,786.30 |