- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,089.30 / $2,818.38
| Facility | | $1,348.96 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $2,398.83
| Professional | | $1,513.56 | $1,698.24 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,511.89 / $2,951.21
| Professional | | $1,412.54 | $2,511.89 | $2,951.21 |
- 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
- $1,513.56 / $1,995.26 / $3,162.28
| Professional | | $1,513.56 | $1,995.26 | $3,162.28 |