- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $4,265.80
| Facility | | $1,380.38 | $2,041.74 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,715.35 / $5,248.07
| Professional | | $3,311.31 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,025.60 / $7,244.36
| Professional | | $1,202.26 | $6,025.60 | $7,244.36 |
- 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
- $3,162.28 / $4,265.80 / $7,079.46
| Professional | | $3,162.28 | $4,265.80 | $7,079.46 |