- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.27 / $1,117.97 / $1,380.31
| Facility | | $1,097.27 | $1,117.97 | $1,380.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.59 / $1,167.04 / $1,646.74
| Professional | | $927.59 | $1,167.04 | $1,646.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,123.00 / $2,272.67 / $4,246.00
| Facility | | $2,123.00 | $2,272.67 | $4,246.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.58 / $1,183.49 / $1,716.72
| Professional | | $1,182.58 | $1,183.49 | $1,716.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.05 / $1,407.05 / $1,407.05
| Facility | | $1,407.05 | $1,407.05 | $1,407.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $2,335.30
| Professional | | $1,027.15 | $1,027.15 | $2,335.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.34 / $1,050.18 / $1,615.66
| Professional | | $802.34 | $1,050.18 | $1,615.66 |