- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,398.83
| Facility | | $1,023.29 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $3,981.07
| Professional | | $1,905.46 | $2,187.76 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $6,606.93
| Facility | | $4,073.80 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $3,630.78
| Professional | | $1,995.26 | $2,818.38 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $3,981.07
| Professional | | $1,621.81 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,265.80 / $6,918.31
| Facility | | $1,202.26 | $4,265.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $3,388.44
| Professional | | $1,548.82 | $2,137.96 | $3,388.44 |