- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.03 / $1,355.21 / $1,606.83
| Facility | | $1,346.03 | $1,355.21 | $1,606.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.81 / $1,384.28 / $1,875.46
| Professional | | $1,155.81 | $1,384.28 | $1,875.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.23 / $2,900.36 / $4,798.78
| Facility | | $2,428.23 | $2,900.36 | $4,798.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.41 / $1,480.00 / $2,153.99
| Professional | | $1,455.41 | $1,480.00 | $2,153.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,549.06 / $1,549.06 / $1,676.94
| Facility | | $1,549.06 | $1,549.06 | $1,676.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.81 / $1,549.06 / $1,712.04
| Professional | | $1,130.81 | $1,549.06 | $1,712.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.52 / $1,257.03 / $1,863.51
| Professional | | $972.52 | $1,257.03 | $1,863.51 |