- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $5,754.40
| Facility | | $2,398.83 | $2,454.71 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,466.84
| Professional | | $2,398.83 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,248.07 / $7,079.46
| Professional | | $4,786.30 | $5,248.07 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $14,791.08 / $14,791.08
| Facility | | $2,137.96 | $14,791.08 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |