- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,691.53 / $3,715.35
| Facility | | $1,584.89 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,467.37
| Professional | | $2,754.23 | $2,754.23 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $2,398.83
| Facility | | $1,174.90 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $891.25 / $1,348.96
| Professional | | $588.84 | $891.25 | $1,348.96 |