- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $3,090.30
| Facility | | $1,288.25 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $2,884.03
| Professional | | $1,862.09 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $4,073.80
| Professional | | $891.25 | $3,235.94 | $4,073.80 |
- 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
- $1,778.28 / $3,235.94 / $4,265.80
| Professional | | $1,778.28 | $3,235.94 | $4,265.80 |