- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $2,454.71
| Facility | | $1,659.59 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $1,737.80
| Professional | | $1,148.15 | $1,513.56 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $2,089.30 / $2,454.71
| Professional | | $954.99 | $2,089.30 | $2,454.71 |
- 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
- $1,148.15 / $1,380.38 / $2,454.71
| Professional | | $1,148.15 | $1,380.38 | $2,454.71 |