- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $2,511.89
| Facility | | $1,513.56 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $2,398.83
| Professional | | $1,412.54 | $1,584.89 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $2,630.27
| Professional | | $1,288.25 | $2,290.87 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $9,332.54
| Facility | | $1,230.27 | $2,951.21 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $2,818.38
| Professional | | $1,412.54 | $1,778.28 | $2,818.38 |