- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $2,754.23
| Facility | | $1,288.25 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,344.23
| Professional | | $1,513.56 | $1,819.70 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,818.38 / $3,548.13
| Professional | | $891.25 | $2,818.38 | $3,548.13 |
- 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
- $1,445.44 / $2,344.23 / $3,388.44
| Professional | | $1,445.44 | $2,344.23 | $3,388.44 |