- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.18 / $1,214.13 / $1,430.61
| Facility | | $1,192.18 | $1,214.13 | $1,430.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.66 / $1,223.17 / $1,682.43
| Professional | | $975.66 | $1,223.17 | $1,682.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,184.78 / $2,552.21 / $4,559.18
| Facility | | $2,184.78 | $2,552.21 | $4,559.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.03 / $1,282.47 / $1,875.42
| Professional | | $1,255.03 | $1,282.47 | $1,875.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.39 / $1,295.39 / $1,430.21
| Facility | | $1,295.39 | $1,295.39 | $1,430.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.63 / $1,295.39 / $1,380.95
| Professional | | $945.63 | $1,295.39 | $1,380.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.88 / $1,156.64 / $1,673.79
| Professional | | $861.88 | $1,156.64 | $1,673.79 |