- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.73 / $1,369.38 / $1,713.74
| Facility | | $1,277.73 | $1,369.38 | $1,713.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.88 / $1,369.38 / $1,916.59
| Professional | | $1,046.88 | $1,369.38 | $1,916.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.14 / $2,870.81 / $5,319.90
| Facility | | $2,412.14 | $2,870.81 | $5,319.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.38 / $1,369.38 / $2,212.01
| Professional | | $1,369.38 | $1,369.38 | $2,212.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $1,461.04
| Facility | | $1,424.68 | $1,424.68 | $1,461.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $3,078.27
| Professional | | $1,040.02 | $1,040.02 | $3,078.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.67 / $1,350.19 / $1,824.00
| Professional | | $961.67 | $1,350.19 | $1,824.00 |