- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $2,570.40
| Facility | | $1,698.24 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,949.84 / $2,691.53
| Professional | | $1,698.24 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,019.95 / $4,466.84
| Professional | | $1,202.26 | $3,019.95 | $4,466.84 |
- 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
- $1,621.81 / $2,290.87 / $3,630.78
| Professional | | $1,621.81 | $2,290.87 | $3,630.78 |