- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $2,511.89
| Facility | | $1,698.24 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,137.96
| Professional | | $1,258.93 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $2,951.21
| Professional | | $1,202.26 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $2,884.03
| Professional | | $1,318.26 | $1,778.28 | $2,884.03 |