- 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 / $3,162.28
| Professional | | $1,995.26 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $3,981.07
| Professional | | $891.25 | $3,235.94 | $3,981.07 |
- 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
- $1,513.56 / $2,041.74 / $4,265.80
| Professional | | $1,513.56 | $2,041.74 | $4,265.80 |