- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,388.44
| Facility | | $1,698.24 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,630.27 / $3,890.45
| Professional | | $2,238.72 | $2,630.27 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,715.35 / $4,365.16
| Professional | | $1,995.26 | $3,715.35 | $4,365.16 |
- 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
- $2,238.72 / $2,884.03 / $4,570.88
| Professional | | $2,238.72 | $2,884.03 | $4,570.88 |