- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,511.89
| Facility | | $1,698.24 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $2,238.72
| Professional | | $1,412.54 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $2,511.89 / $3,162.28
| Professional | | $602.56 | $2,511.89 | $3,162.28 |
- 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
- $1,380.38 / $1,905.46 / $3,019.95
| Professional | | $1,380.38 | $1,905.46 | $3,019.95 |