- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $2,454.71
| Facility | | $1,380.38 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $1,548.82
| Professional | | $1,096.48 | $1,230.27 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $2,089.30 / $2,691.53
| Professional | | $870.96 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,096.48 / $2,570.40
| Facility | | $588.84 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $2,344.23
| Professional | | $1,023.29 | $1,258.93 | $2,344.23 |