- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,454.71
| Facility | | $1,513.56 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,348.96 / $1,862.09
| Professional | | $1,174.90 | $1,348.96 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $2,570.40
| Professional | | $891.25 | $2,041.74 | $2,570.40 |
- 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
- $1,148.15 / $1,548.82 / $2,511.89
| Professional | | $1,148.15 | $1,548.82 | $2,511.89 |