- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,515.86 / $2,802.69 / $3,738.19
| Facility | | $1,515.86 | $2,802.69 | $3,738.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,537.90
| Professional | | $1,214.63 | $1,214.63 | $1,537.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.71 / $2,715.65 / $6,943.25
| Facility | | $1,351.71 | $2,715.65 | $6,943.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.05 / $1,214.63 / $1,821.95
| Professional | | $1,166.05 | $1,214.63 | $1,821.95 |