- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.25 / $2,327.73 / $4,149.83
| Facility | | $1,262.25 | $2,327.73 | $4,149.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.65 / $1,218.07 / $1,262.25
| Professional | | $1,024.65 | $1,218.07 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,163.13 / $1,350.71 / $3,681.60
| Facility | | $1,163.13 | $1,350.71 | $3,681.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.12 / $1,237.50 / $1,361.25
| Professional | | $928.12 | $1,237.50 | $1,361.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Professional | | $1,262.25 | $1,262.25 | $1,262.25 |