- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,570.40
| Facility | | $1,698.24 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,235.94
| Professional | | $1,995.26 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $3,311.31 / $4,073.80
| Professional | | $891.25 | $3,311.31 | $4,073.80 |
- 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 / $2,089.30 / $4,365.16
| Professional | | $1,548.82 | $2,089.30 | $4,365.16 |