- 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
- $3,019.95 / $3,467.37 / $4,570.88
| Professional | | $3,019.95 | $3,467.37 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,786.30 / $5,754.40
| Professional | | $2,630.27 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $14,454.40
| Facility | | $2,187.76 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $6,165.95
| Professional | | $2,884.03 | $3,801.89 | $6,165.95 |