- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.77 / $1,237.29 / $1,553.29
| Facility | | $1,234.77 | $1,237.29 | $1,553.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.18 / $1,237.29 / $1,831.67
| Professional | | $1,066.18 | $1,237.29 | $1,831.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,389.03 / $2,557.50 / $4,778.06
| Facility | | $2,389.03 | $2,557.50 | $4,778.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.86 / $1,335.86 / $1,982.40
| Professional | | $1,335.86 | $1,335.86 | $1,982.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,366.32
| Facility | | $1,366.32 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $1,366.32 / $1,426.78
| Professional | | $997.41 | $1,366.32 | $1,426.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.90 / $1,227.75 / $1,795.38
| Professional | | $931.90 | $1,227.75 | $1,795.38 |