- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,341.23 / $1,345.34 / $1,695.13
| Facility | | $1,341.23 | $1,345.34 | $1,695.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.57 / $1,399.66 / $1,959.84
| Professional | | $1,043.57 | $1,399.66 | $1,959.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,332.77 / $2,780.34 / $5,129.22
| Facility | | $2,332.77 | $2,780.34 | $5,129.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.96 / $1,425.16 / $2,108.69
| Professional | | $1,411.96 | $1,425.16 | $2,108.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $1,823.10
| Facility | | $1,823.10 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $1,877.79
| Professional | | $1,330.86 | $1,823.10 | $1,877.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.83 / $1,332.22 / $1,853.18
| Professional | | $969.83 | $1,332.22 | $1,853.18 |