- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $2,454.71
| Facility | | $1,412.54 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $1,862.09
| Professional | | $1,202.26 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $2,630.27
| Professional | | $1,174.90 | $1,862.09 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,606.93 / $12,022.64
| Facility | | $3,715.35 | $6,606.93 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $2,454.71
| Professional | | $1,148.15 | $1,513.56 | $2,454.71 |