- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,454.71
| Facility | | $1,445.44 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $1,445.44
| Professional | | $1,096.48 | $1,258.93 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,905.46 / $2,187.76
| Professional | | $912.01 | $1,905.46 | $2,187.76 |
- 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 / $1,288.25 / $2,344.23
| Professional | | $1,047.13 | $1,288.25 | $2,344.23 |