- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,235.94 / $4,365.16
| Facility | | $933.25 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $4,265.80
| Professional | | $2,570.40 | $3,388.44 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $4,677.35
| Professional | | $2,137.96 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,230.27 / $6,165.95
| Facility | | $389.05 | $1,230.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $5,248.07
| Professional | | $2,238.72 | $3,548.13 | $5,248.07 |