- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $3,090.30
| Facility | | $1,288.25 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $2,290.87
| Professional | | $1,659.59 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,884.03 / $3,388.44
| Professional | | $1,258.93 | $2,884.03 | $3,388.44 |
- 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
- $1,584.89 / $1,905.46 / $3,311.31
| Professional | | $1,584.89 | $1,905.46 | $3,311.31 |