- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,454.71
| Facility | | $1,445.44 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $1,778.28
| Professional | | $1,122.02 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,949.84 / $2,454.71
| Professional | | $891.25 | $1,949.84 | $2,454.71 |
- 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
- $1,096.48 / $1,513.56 / $2,398.83
| Professional | | $1,096.48 | $1,513.56 | $2,398.83 |