- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,511.89
| Facility | | $1,288.25 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,454.71
| Professional | | $1,230.27 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,073.80
| Professional | | $1,995.26 | $2,691.53 | $4,073.80 |
- 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
- $1,174.90 / $1,698.24 / $3,019.95
| Professional | | $1,174.90 | $1,698.24 | $3,019.95 |