- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,454.71
| Facility | | $1,479.11 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $1,862.09
| Professional | | $1,202.26 | $1,348.96 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,995.26 / $2,570.40
| Professional | | $891.25 | $1,995.26 | $2,570.40 |
- 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
- $1,122.02 / $1,584.89 / $2,511.89
| Professional | | $1,122.02 | $1,584.89 | $2,511.89 |