- 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
- $1,862.09 / $2,089.30 / $3,235.94
| Professional | | $1,862.09 | $2,089.30 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,235.94 / $3,801.89
| Professional | | $1,698.24 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,570.88 / $8,709.64
| Facility | | $2,089.30 | $4,570.88 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $4,073.80
| Professional | | $1,862.09 | $2,691.53 | $4,073.80 |