- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $3,090.30
| Facility | | $1,380.38 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,818.38
| Professional | | $1,819.70 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $3,162.28 / $3,981.07
| Professional | | $891.25 | $3,162.28 | $3,981.07 |
- 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
- $1,659.59 / $2,454.71 / $3,801.89
| Professional | | $1,659.59 | $2,454.71 | $3,801.89 |