- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,454.71
| Facility | | $1,513.56 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,380.38 / $1,905.46
| Professional | | $1,258.93 | $1,380.38 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,187.76 / $2,630.27
| Professional | | $891.25 | $2,187.76 | $2,630.27 |
- 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
- $1,174.90 / $1,659.59 / $2,570.40
| Professional | | $1,174.90 | $1,659.59 | $2,570.40 |