- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,454.71
| Facility | | $1,479.11 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,258.93 / $1,819.70
| Professional | | $1,148.15 | $1,258.93 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,995.26 / $2,511.89
| Professional | | $478.63 | $1,995.26 | $2,511.89 |
- 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
- $1,096.48 / $1,445.44 / $2,454.71
| Professional | | $1,096.48 | $1,445.44 | $2,454.71 |