- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,511.89
| Facility | | $1,698.24 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $2,137.96
| Professional | | $1,479.11 | $1,819.70 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,570.40 / $3,019.95
| Professional | | $1,174.90 | $2,570.40 | $3,019.95 |
- 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
- $1,412.54 / $1,659.59 / $3,019.95
| Professional | | $1,412.54 | $1,659.59 | $3,019.95 |