- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $2,691.53
| Facility | | $1,698.24 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $3,019.95
| Professional | | $1,862.09 | $2,344.23 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,548.13 / $4,570.88
| Professional | | $1,479.11 | $3,548.13 | $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
- $1,737.80 / $2,187.76 / $4,073.80
| Professional | | $1,737.80 | $2,187.76 | $4,073.80 |