- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.76 / $1,765.81 / $2,383.84
| Facility | | $1,351.76 | $1,765.81 | $2,383.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.88 / $1,765.81 / $1,765.81
| Professional | | $835.88 | $1,765.81 | $1,765.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.66 / $1,191.66 / $1,191.66
| Professional | | $1,191.66 | $1,191.66 | $1,191.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.20 / $1,184.20 / $2,156.12
| Facility | | $1,184.20 | $1,184.20 | $2,156.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.47 / $1,184.20 / $1,911.98
| Professional | | $864.47 | $1,184.20 | $1,911.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.08 / $880.62 / $1,344.67
| Professional | | $587.08 | $880.62 | $1,344.67 |