- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,691.53 / $4,073.80
| Facility | | $1,258.93 | $2,691.53 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,318.26 / $2,691.53
| Professional | | $1,096.48 | $1,318.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,691.53 / $5,623.41
| Facility | | $1,380.38 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,819.70
| Professional | | $1,202.26 | $1,258.93 | $1,819.70 |