- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,995.26 / $2,511.89
| Facility | | $1,698.24 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $2,454.71
| Professional | | $1,548.82 | $1,905.46 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,344.23 / $3,467.37
| Professional | | $1,479.11 | $2,344.23 | $3,467.37 |
- 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
- $1,513.56 / $1,949.84 / $3,090.30
| Professional | | $1,513.56 | $1,949.84 | $3,090.30 |