- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $3,090.30
| Facility | | $1,698.24 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $3,019.95
| Professional | | $1,949.84 | $2,344.23 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,818.38 / $3,801.89
| Professional | | $1,659.59 | $2,818.38 | $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
- $1,819.70 / $2,454.71 / $4,073.80
| Professional | | $1,819.70 | $2,454.71 | $4,073.80 |