- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,995.26 / $2,511.89
| Facility | | $1,698.24 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $2,187.76
| Professional | | $1,412.54 | $1,548.82 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $2,290.87 / $3,019.95
| Professional | | $602.56 | $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
- $1,288.25 / $1,584.89 / $2,951.21
| Professional | | $1,288.25 | $1,584.89 | $2,951.21 |