- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $2,691.53
| Facility | | $1,698.24 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,630.27
| Professional | | $1,698.24 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,951.21 / $3,630.78
| Professional | | $891.25 | $2,951.21 | $3,630.78 |
- 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
- $1,621.81 / $2,238.72 / $3,548.13
| Professional | | $1,621.81 | $2,238.72 | $3,548.13 |