- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,918.31 / $6,918.31
| Facility | | $2,818.38 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $2,691.53
| Professional | | $1,995.26 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,235.94 / $3,630.78
| Professional | | $2,884.03 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,162.28 / $3,715.35
| Professional | | $1,737.80 | $3,162.28 | $3,715.35 |