- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $2,511.89
| Facility | | $1,698.24 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $2,344.23
| Professional | | $1,659.59 | $1,862.09 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,162.28 / $4,073.80
| Professional | | $1,318.26 | $3,162.28 | $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
- $1,548.82 / $1,949.84 / $3,630.78
| Professional | | $1,548.82 | $1,949.84 | $3,630.78 |