- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $2,454.71
| Facility | | $1,230.27 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,089.30
| Professional | | $1,412.54 | $1,905.46 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,691.53 / $3,090.30
| Professional | | $1,288.25 | $2,691.53 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,041.74 / $5,495.41
| Facility | | $1,230.27 | $2,041.74 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $3,235.94
| Professional | | $1,445.44 | $1,778.28 | $3,235.94 |