- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,454.71
| Facility | | $1,513.56 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $1,584.89
| Professional | | $1,047.13 | $1,380.38 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,905.46 / $2,238.72
| Professional | | $891.25 | $1,905.46 | $2,238.72 |
- 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
- $1,047.13 / $1,230.27 / $2,238.72
| Professional | | $1,047.13 | $1,230.27 | $2,238.72 |