- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,333.71 / $3,176.94 / $11,580.10
| Facility | | $2,333.71 | $3,176.94 | $11,580.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.22 / $2,443.80 / $2,862.11
| Professional | | $1,651.22 | $2,443.80 | $2,862.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,431.05 / $1,431.05 / $1,431.05
| Facility | | $1,431.05 | $1,431.05 | $1,431.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,529.63 / $3,162.03
| Professional | | $2,529.63 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $1,100.81 / $2,972.19
| Professional | | $924.68 | $1,100.81 | $2,972.19 |