- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,433.74 / $2,444.02
| Facility | | $1,400.00 | $1,433.74 | $2,444.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.43 / $1,591.23 / $2,054.85
| Professional | | $1,386.43 | $1,591.23 | $2,054.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,628.35 / $1,892.71 / $2,062.14
| Facility | | $1,628.35 | $1,892.71 | $2,062.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.36 / $1,833.01 / $1,833.01
| Professional | | $940.36 | $1,833.01 | $1,833.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.76 / $1,743.76 / $1,743.76
| Facility | | $1,743.76 | $1,743.76 | $1,743.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.05 / $2,121.10 / $3,761.90
| Professional | | $1,472.05 | $2,121.10 | $3,761.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.00 / $1,758.14 / $2,418.41
| Professional | | $1,062.00 | $1,758.14 | $2,418.41 |