- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.35 / $1,318.78 / $1,542.43
| Facility | | $1,285.35 | $1,318.78 | $1,542.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.22 / $1,311.06 / $1,984.29
| Professional | | $1,138.22 | $1,311.06 | $1,984.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,281.30 / $2,666.02 / $4,915.55
| Facility | | $2,281.30 | $2,666.02 | $4,915.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.68 / $1,381.04 / $1,905.83
| Professional | | $1,374.68 | $1,381.04 | $1,905.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,747.16
| Facility | | $1,747.16 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,709.61 / $1,799.57
| Professional | | $1,275.43 | $1,709.61 | $1,799.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.81 / $1,329.43 / $1,788.64
| Professional | | $939.81 | $1,329.43 | $1,788.64 |