- 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
- $1,548.82 / $1,698.24 / $2,344.23
| Professional | | $1,548.82 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,630.27 / $3,311.31
| Professional | | $891.25 | $2,630.27 | $3,311.31 |
- 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
- $1,445.44 / $1,995.26 / $3,235.94
| Professional | | $1,445.44 | $1,995.26 | $3,235.94 |