- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $4,265.80
| Facility | | $1,698.24 | $2,511.89 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,311.31 / $4,570.88
| Professional | | $2,884.03 | $3,311.31 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,786.30 / $6,309.57
| Professional | | $1,202.26 | $4,786.30 | $6,309.57 |
- 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
- $2,570.40 / $3,235.94 / $6,165.95
| Professional | | $2,570.40 | $3,235.94 | $6,165.95 |