- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $2,454.71
| Facility | | $1,659.59 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $1,819.70
| Professional | | $1,318.26 | $1,584.89 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,238.72 / $2,511.89
| Professional | | $977.24 | $2,238.72 | $2,511.89 |
- 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
- $1,202.26 / $1,479.11 / $2,630.27
| Professional | | $1,202.26 | $1,479.11 | $2,630.27 |