- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $3,311.31
| Facility | | $1,698.24 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $2,344.23
| Professional | | $1,445.44 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,238.72 / $2,754.23
| Professional | | $1,348.96 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $19,498.45
| Facility | | $3,715.35 | $7,762.47 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $2,951.21
| Professional | | $1,445.44 | $1,862.09 | $2,951.21 |