- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,090.30
| Facility | | $1,698.24 | $2,511.89 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $3,235.94
| Professional | | $1,995.26 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $3,801.89
| Professional | | $1,819.70 | $3,311.31 | $3,801.89 |
- 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
- $1,995.26 / $2,570.40 / $4,073.80
| Professional | | $1,995.26 | $2,570.40 | $4,073.80 |