- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.75 / $1,063.68 / $1,352.62
| Facility | | $1,060.75 | $1,063.68 | $1,352.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.70 / $1,128.88 / $1,581.93
| Professional | | $893.70 | $1,128.88 | $1,581.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.87 / $2,284.19 / $4,275.97
| Facility | | $1,949.87 | $2,284.19 | $4,275.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.02 / $1,136.98 / $1,608.75
| Professional | | $1,102.02 | $1,136.98 | $1,608.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,277.46 / $1,277.46
| Facility | | $1,277.46 | $1,277.46 | $1,277.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.55 / $1,277.46 / $1,498.02
| Professional | | $932.55 | $1,277.46 | $1,498.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.16 / $998.71 / $1,555.47
| Professional | | $762.16 | $998.71 | $1,555.47 |