- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $2,454.71
| Facility | | $1,122.02 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,412.54
| Professional | | $1,071.52 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,905.46 / $2,630.27
| Professional | | $851.14 | $1,905.46 | $2,630.27 |
- 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
- $870.96 / $1,202.26 / $2,290.87
| Professional | | $870.96 | $1,202.26 | $2,290.87 |