- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $2,511.89
| Facility | | $1,698.24 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,187.76
| Professional | | $1,380.38 | $1,584.89 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,398.83 / $3,019.95
| Professional | | $891.25 | $2,398.83 | $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
- $1,318.26 / $1,778.28 / $2,951.21
| Professional | | $1,318.26 | $1,778.28 | $2,951.21 |