- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,235.94
| Facility | | $1,698.24 | $2,511.89 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $3,311.31
| Professional | | $2,290.87 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,466.84 / $5,495.41
| Professional | | $1,819.70 | $4,466.84 | $5,495.41 |
- 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 / $2,691.53 / $5,011.87
| Professional | | $2,137.96 | $2,691.53 | $5,011.87 |