- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,570.40
| Facility | | $1,380.38 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $2,187.76
| Professional | | $1,412.54 | $1,584.89 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $2,454.71 / $3,090.30
| Professional | | $478.63 | $2,454.71 | $3,090.30 |
- 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
- $1,348.96 / $1,905.46 / $2,951.21
| Professional | | $1,348.96 | $1,905.46 | $2,951.21 |