- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $2,454.71
| Facility | | $1,698.24 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,548.82 / $2,137.96
| Professional | | $1,348.96 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,344.23 / $2,951.21
| Professional | | $891.25 | $2,344.23 | $2,951.21 |
- 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
- $1,288.25 / $1,862.09 / $2,884.03
| Professional | | $1,288.25 | $1,862.09 | $2,884.03 |