- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $2,951.21
| Facility | | $1,698.24 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $3,019.95
| Professional | | $1,905.46 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,388.44 / $4,570.88
| Professional | | $1,202.26 | $3,388.44 | $4,570.88 |
- 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
- $1,819.70 / $2,630.27 / $4,073.80
| Professional | | $1,819.70 | $2,630.27 | $4,073.80 |