- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $2,454.71
| Facility | | $1,621.81 | $1,819.70 | $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 / $1,995.26 / $2,344.23
| Professional | | $1,174.90 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $16,982.44
| Facility | | $2,187.76 | $5,888.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,570.40
| Professional | | $1,230.27 | $1,584.89 | $2,570.40 |