- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,039.10 / $1,039.10 / $1,232.01
| Facility | | $1,039.10 | $1,039.10 | $1,232.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.75 / $1,039.10 / $1,498.95
| Professional | | $832.75 | $1,039.10 | $1,498.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,843.13 / $2,373.03 / $3,671.82
| Facility | | $1,843.13 | $2,373.03 | $3,671.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.40 / $1,086.33 / $1,499.14
| Professional | | $1,052.40 | $1,086.33 | $1,499.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $1,395.53 / $1,395.53
| Facility | | $1,395.53 | $1,395.53 | $1,395.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $2,212.96
| Professional | | $1,018.74 | $1,018.74 | $2,212.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.24 / $915.92 / $1,483.09
| Professional | | $737.24 | $915.92 | $1,483.09 |