- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $2,511.89
| Facility | | $1,122.02 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $1,412.54
| Professional | | $870.96 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,621.81 / $2,041.74
| Professional | | $602.56 | $1,621.81 | $2,041.74 |
- 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
- $870.96 / $1,202.26 / $1,995.26
| Professional | | $870.96 | $1,202.26 | $1,995.26 |