- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $2,454.71
| Facility | | $1,584.89 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $1,949.84
| Professional | | $1,230.27 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,238.72 / $2,754.23
| Professional | | $891.25 | $2,238.72 | $2,754.23 |
- 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 / $2,630.27
| Professional | | $1,174.90 | $1,659.59 | $2,630.27 |