- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $2,511.89
| Facility | | $1,513.56 | $1,905.46 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $5,495.41
| Professional | | $1,412.54 | $1,621.81 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $2,691.53
| Professional | | $1,288.25 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $11,748.98
| Facility | | $1,548.82 | $4,073.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $2,884.03
| Professional | | $1,380.38 | $1,778.28 | $2,884.03 |