- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $2,511.89
| Facility | | $1,698.24 | $2,187.76 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $3,090.30
| Professional | | $1,949.84 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,235.94 / $4,265.80
| Professional | | $1,202.26 | $3,235.94 | $4,265.80 |
- 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
- $1,737.80 / $2,238.72 / $4,168.69
| Professional | | $1,737.80 | $2,238.72 | $4,168.69 |