- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,388.44
| Facility | | $1,698.24 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,884.03 / $3,715.35
| Professional | | $2,344.23 | $2,884.03 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,715.35 / $5,248.07
| Professional | | $2,187.76 | $3,715.35 | $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
- $2,238.72 / $2,951.21 / $4,677.35
| Professional | | $2,238.72 | $2,951.21 | $4,677.35 |