- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,454.71
| Facility | | $1,513.56 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $2,041.74
| Professional | | $1,258.93 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $2,398.83
| Professional | | $1,174.90 | $1,819.70 | $2,398.83 |
- 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
- $1,258.93 / $1,621.81 / $2,570.40
| Professional | | $1,258.93 | $1,621.81 | $2,570.40 |