- 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
- $1,445.44 / $1,737.80 / $2,041.74
| Professional | | $1,445.44 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $3,715.35
| Professional | | $1,230.27 | $2,951.21 | $3,715.35 |
- 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
- $1,412.54 / $1,778.28 / $3,311.31
| Professional | | $1,412.54 | $1,778.28 | $3,311.31 |