- 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
- $1,148.15 / $1,698.24 / $1,995.26
| Professional | | $1,148.15 | $1,698.24 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,754.23 / $3,715.35
| Professional | | $1,202.26 | $2,754.23 | $3,715.35 |
- 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
- $1,288.25 / $1,737.80 / $3,235.94
| Professional | | $1,288.25 | $1,737.80 | $3,235.94 |