- 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
- $2,187.76 / $2,511.89 / $3,467.37
| Professional | | $2,187.76 | $2,511.89 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,073.80 / $4,897.79
| Professional | | $1,202.26 | $4,073.80 | $4,897.79 |
- 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
- $2,137.96 / $2,884.03 / $4,786.30
| Professional | | $2,137.96 | $2,884.03 | $4,786.30 |