- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $4,168.69
| Facility | | $1,513.56 | $1,995.26 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,311.31 / $4,466.84
| Professional | | $2,884.03 | $3,311.31 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,786.30 / $5,623.41
| Professional | | $2,754.23 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,801.89 / $6,025.60
| Professional | | $2,951.21 | $3,801.89 | $6,025.60 |