- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,019.95
| Facility | | $1,698.24 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,344.23 / $2,951.21
| Professional | | $2,089.30 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,073.80 / $5,128.61
| Professional | | $1,659.59 | $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
- $1,949.84 / $2,454.71 / $4,570.88
| Professional | | $1,949.84 | $2,454.71 | $4,570.88 |