- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,311.31 / $7,762.47
| Facility | | $1,698.24 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $3,801.89
| Professional | | $2,570.40 | $3,311.31 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,890.45 / $6,760.83
| Professional | | $2,818.38 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,888.44
| Professional | | $5,248.07 | $5,248.07 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,311.31 / $7,244.36
| Professional | | $1,905.46 | $3,311.31 | $7,244.36 |