- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.26 / $1,317.10 / $1,546.22
| Facility | | $1,278.26 | $1,317.10 | $1,546.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.65 / $1,317.10 / $2,033.66
| Professional | | $1,123.65 | $1,317.10 | $2,033.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,288.40 / $2,832.31 / $4,888.02
| Facility | | $2,288.40 | $2,832.31 | $4,888.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.04 / $1,398.04 / $1,929.29
| Professional | | $1,398.04 | $1,398.04 | $1,929.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.63 / $1,665.63 / $1,665.63
| Facility | | $1,665.63 | $1,665.63 | $1,665.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,665.63 / $1,810.28
| Professional | | $1,215.91 | $1,665.63 | $1,810.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.80 / $1,284.55 / $1,812.81
| Professional | | $1,014.80 | $1,284.55 | $1,812.81 |