- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $2,570.40
| Facility | | $1,698.24 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $2,630.27
| Professional | | $1,659.59 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,884.03 / $3,630.78
| Professional | | $1,202.26 | $2,884.03 | $3,630.78 |
- 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 / $2,238.72 / $3,548.13
| Professional | | $1,584.89 | $2,238.72 | $3,548.13 |