- 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
- $1,698.24 / $1,949.84 / $2,454.71
| Professional | | $1,698.24 | $1,949.84 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,311.31 / $4,168.69
| Professional | | $1,348.96 | $3,311.31 | $4,168.69 |
- 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
- $1,584.89 / $1,995.26 / $3,715.35
| Professional | | $1,584.89 | $1,995.26 | $3,715.35 |