- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,369.35 / $1,460.17 / $2,277.87
| Facility | | $1,369.35 | $1,460.17 | $2,277.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.61 / $1,306.47 / $2,277.87
| Professional | | $1,229.61 | $1,306.47 | $2,277.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.83 / $1,077.83 / $1,077.83
| Facility | | $1,077.83 | $1,077.83 | $1,077.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.95 / $1,077.83 / $1,198.88
| Professional | | $1,023.95 | $1,077.83 | $1,198.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.37 / $1,873.37 / $2,341.71
| Professional | | $1,873.37 | $1,873.37 | $2,341.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.17 / $1,460.17 / $2,683.06
| Facility | | $1,460.17 | $1,460.17 | $2,683.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.54 / $1,475.54 / $1,844.42
| Professional | | $1,475.54 | $1,475.54 | $1,844.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,537.02 / $1,844.42
| Facility | | $1,537.02 | $1,537.02 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $1,537.02
| Professional | | $645.54 | $922.21 | $1,537.02 |