- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $2,818.38
| Facility | | $1,698.24 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $3,019.95
| Professional | | $1,905.46 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,162.28 / $4,168.69
| Professional | | $1,202.26 | $3,162.28 | $4,168.69 |
- 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
- $1,862.09 / $2,187.76 / $4,073.80
| Professional | | $1,862.09 | $2,187.76 | $4,073.80 |