- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $2,454.71
| Facility | | $1,621.81 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $1,737.80
| Professional | | $1,202.26 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,995.26 / $2,398.83
| Professional | | $954.99 | $1,995.26 | $2,398.83 |
- 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
- $1,122.02 / $1,348.96 / $2,454.71
| Professional | | $1,122.02 | $1,348.96 | $2,454.71 |