- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $2,511.89
| Facility | | $1,698.24 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $2,187.76
| Professional | | $1,348.96 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,290.87 / $3,019.95
| Professional | | $891.25 | $2,290.87 | $3,019.95 |
- 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
- $1,230.27 / $1,659.59 / $2,951.21
| Professional | | $1,230.27 | $1,659.59 | $2,951.21 |