- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $2,454.71
| Facility | | $1,659.59 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,041.74
| Professional | | $1,202.26 | $1,479.11 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,089.30 / $2,818.38
| Professional | | $891.25 | $2,089.30 | $2,818.38 |
- 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
- $1,258.93 / $1,548.82 / $2,754.23
| Professional | | $1,258.93 | $1,548.82 | $2,754.23 |