- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $2,454.71
| Facility | | $1,548.82 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $1,659.59
| Professional | | $1,096.48 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,041.74 / $2,344.23
| Professional | | $912.01 | $2,041.74 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $6,918.31
| Facility | | $1,548.82 | $4,073.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $2,344.23
| Professional | | $1,071.52 | $1,288.25 | $2,344.23 |