- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $2,511.89
| Facility | | $1,698.24 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $1,862.09
| Professional | | $1,380.38 | $1,621.81 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,290.87 / $2,570.40
| Professional | | $1,047.13 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,754.23
| Professional | | $1,318.26 | $1,548.82 | $2,754.23 |