- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $2,754.23
| Facility | | $1,698.24 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $2,691.53
| Professional | | $1,862.09 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,818.38 / $3,630.78
| Professional | | $1,513.56 | $2,818.38 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $3,890.45
| Professional | | $1,698.24 | $2,137.96 | $3,890.45 |