- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,511.89
| Facility | | $1,698.24 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,584.89 / $2,238.72
| Professional | | $1,513.56 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,818.38 / $3,162.28
| Professional | | $1,288.25 | $2,818.38 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,570.40 / $6,918.31
| Facility | | $1,548.82 | $2,570.40 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $3,311.31
| Professional | | $1,513.56 | $1,862.09 | $3,311.31 |