- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $3,090.30
| Facility | | $1,380.38 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,630.27
| Professional | | $1,698.24 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,951.21 / $3,715.35
| Professional | | $891.25 | $2,951.21 | $3,715.35 |
- 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
- $1,548.82 / $2,290.87 / $3,548.13
| Professional | | $1,548.82 | $2,290.87 | $3,548.13 |