- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,511.89
| Facility | | $1,698.24 | $1,905.46 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,659.59 / $2,041.74
| Professional | | $1,479.11 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,754.23 / $3,630.78
| Professional | | $1,174.90 | $2,754.23 | $3,630.78 |
- 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
- $1,380.38 / $1,698.24 / $3,162.28
| Professional | | $1,380.38 | $1,698.24 | $3,162.28 |