- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $2,511.89
| Facility | | $1,288.25 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $2,041.74
| Professional | | $1,318.26 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,454.71 / $3,019.95
| Professional | | $891.25 | $2,454.71 | $3,019.95 |
- 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
- $1,258.93 / $1,995.26 / $2,884.03
| Professional | | $1,258.93 | $1,995.26 | $2,884.03 |