- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,084.40 / $1,108.04 / $1,346.95
| Facility | | $1,084.40 | $1,108.04 | $1,346.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.56 / $1,159.95 / $1,563.02
| Professional | | $870.56 | $1,159.95 | $1,563.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,034.31 / $2,575.08 / $4,699.35
| Facility | | $2,034.31 | $2,575.08 | $4,699.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.45 / $1,176.26 / $1,608.93
| Professional | | $1,174.45 | $1,176.26 | $1,608.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.80 / $1,206.80 / $1,206.80
| Facility | | $1,206.80 | $1,206.80 | $1,206.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.96 / $1,206.80 / $1,385.49
| Professional | | $880.96 | $1,206.80 | $1,385.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.61 / $965.36 / $1,692.64
| Professional | | $816.61 | $965.36 | $1,692.64 |