- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,171.33 / $1,475.67 / $2,336.27
| Facility | | $1,171.33 | $1,475.67 | $2,336.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.33 / $1,550.24 / $2,728.71
| Professional | | $1,171.33 | $1,550.24 | $2,728.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.10 / $1,289.08 / $1,548.13
| Facility | | $1,184.10 | $1,289.08 | $1,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.93 / $1,376.11 / $1,376.11
| Professional | | $898.93 | $1,376.11 | $1,376.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,067.04 / $2,067.04 / $2,067.04
| Facility | | $2,067.04 | $2,067.04 | $2,067.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.98 / $2,131.37 / $5,094.68
| Professional | | $1,274.98 | $2,131.37 | $5,094.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.18 / $1,935.98 / $2,744.38
| Professional | | $1,259.18 | $1,935.98 | $2,744.38 |