- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.28 / $1,682.26 / $2,245.85
| Facility | | $1,673.28 | $1,682.26 | $2,245.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.26 / $2,337.77 / $6,092.28
| Professional | | $1,682.26 | $2,337.77 | $6,092.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.35 / $1,549.35 / $1,549.35
| Professional | | $1,549.35 | $1,549.35 | $1,549.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.60 / $2,002.29 / $2,148.87
| Professional | | $1,234.60 | $2,002.29 | $2,148.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.39 / $1,638.93 / $2,950.23
| Professional | | $1,207.39 | $1,638.93 | $2,950.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.15 / $1,603.75 / $3,942.87
| Professional | | $1,115.15 | $1,603.75 | $3,942.87 |