- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,090.30
| Facility | | $1,698.24 | $2,511.89 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $2,884.03
| Professional | | $2,137.96 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,168.69 / $5,248.07
| Professional | | $1,698.24 | $4,168.69 | $5,248.07 |
- 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
- $1,995.26 / $2,511.89 / $4,677.35
| Professional | | $1,995.26 | $2,511.89 | $4,677.35 |