- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $2,454.71
| Facility | | $1,148.15 | $1,621.81 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,023.29 / $1,412.54
| Professional | | $912.01 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,659.59 / $2,041.74
| Professional | | $602.56 | $1,659.59 | $2,041.74 |
- 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
- $870.96 / $1,230.27 / $1,905.46
| Professional | | $870.96 | $1,230.27 | $1,905.46 |