- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,731.23 / $1,846.05 / $2,879.84
| Facility | | $1,731.23 | $1,846.05 | $2,879.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.57 / $1,661.44 / $3,230.59
| Professional | | $1,554.57 | $1,661.44 | $3,230.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,362.68 / $1,362.68 / $1,362.68
| Facility | | $1,362.68 | $1,362.68 | $1,362.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.55 / $1,362.68 / $1,515.71
| Professional | | $1,294.55 | $1,362.68 | $1,515.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.14 / $2,368.14 / $2,960.18
| Professional | | $2,368.14 | $2,368.14 | $2,960.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.05 / $1,846.05 / $3,392.12
| Facility | | $1,846.05 | $1,846.05 | $3,392.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.48 / $1,865.48 / $2,446.19
| Professional | | $1,865.48 | $1,865.48 | $2,446.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $1,943.21
| Professional | | $816.15 | $1,165.93 | $1,943.21 |