- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,715.35
| Facility | | $1,698.24 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,630.27 / $3,630.78
| Professional | | $2,398.83 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $4,073.80 / $5,128.61
| Professional | | $891.25 | $4,073.80 | $5,128.61 |
- 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
- $2,238.72 / $2,884.03 / $4,897.79
| Professional | | $2,238.72 | $2,884.03 | $4,897.79 |