- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $2,511.89
| Facility | | $1,698.24 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $2,630.27
| Professional | | $1,659.59 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,570.40 / $3,715.35
| Professional | | $1,584.89 | $2,570.40 | $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
- $1,621.81 / $2,089.30 / $3,311.31
| Professional | | $1,621.81 | $2,089.30 | $3,311.31 |