- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.48 / $1,112.81 / $1,347.21
| Facility | | $1,107.48 | $1,112.81 | $1,347.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.15 / $1,148.65 / $1,620.32
| Professional | | $929.15 | $1,148.65 | $1,620.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.84 / $2,414.90 / $4,288.84
| Facility | | $2,068.84 | $2,414.90 | $4,288.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.46 / $1,247.18 / $1,694.78
| Professional | | $1,188.46 | $1,247.18 | $1,694.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,304.10 / $1,304.10
| Facility | | $1,304.10 | $1,304.10 | $1,304.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $1,304.10 / $1,343.23
| Professional | | $952.00 | $1,304.10 | $1,343.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.36 / $1,010.30 / $1,571.29
| Professional | | $832.36 | $1,010.30 | $1,571.29 |