- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,398.83
| Facility | | $1,202.26 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,570.40
| Professional | | $1,202.26 | $1,513.56 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $4,786.30
| Facility | | $2,951.21 | $3,548.13 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $1,949.84
| Professional | | $1,148.15 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,659.59 / $2,137.96
| Professional | | $954.99 | $1,659.59 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,128.61
| Facility | | $1,122.02 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $2,041.74
| Professional | | $912.01 | $1,258.93 | $2,041.74 |