- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.73 / $1,038.04 / $1,322.65
| Facility | | $1,011.73 | $1,038.04 | $1,322.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.33 / $1,048.20 / $1,468.88
| Professional | | $802.33 | $1,048.20 | $1,468.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.40 / $2,188.77 / $3,869.14
| Facility | | $1,747.40 | $2,188.77 | $3,869.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.60 / $1,062.60 / $1,677.99
| Professional | | $1,062.60 | $1,062.60 | $1,677.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,375.24 / $1,375.24
| Facility | | $1,375.24 | $1,375.24 | $1,375.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.93 / $1,375.24 / $1,416.50
| Professional | | $1,003.93 | $1,375.24 | $1,416.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.39 / $1,021.57 / $1,382.60
| Professional | | $750.39 | $1,021.57 | $1,382.60 |