- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,041.57 / $1,061.22 / $1,310.23
| Facility | | $1,041.57 | $1,061.22 | $1,310.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.51 / $1,107.78 / $1,563.09
| Professional | | $880.51 | $1,107.78 | $1,563.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.23 / $2,157.29 / $4,030.46
| Facility | | $2,015.23 | $2,157.29 | $4,030.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.35 / $1,123.35 / $1,689.93
| Professional | | $1,123.35 | $1,123.35 | $1,689.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.63 / $1,335.63 / $1,335.63
| Facility | | $1,335.63 | $1,335.63 | $1,335.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $1,248.33 / $1,375.70
| Professional | | $975.01 | $1,248.33 | $1,375.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.82 / $1,005.38 / $1,624.72
| Professional | | $766.82 | $1,005.38 | $1,624.72 |