- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,707.11 / $1,748.25 / $2,118.46
| Facility | | $1,707.11 | $1,748.25 | $2,118.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,707.11 / $1,748.25
| Professional | | $1,645.41 | $1,707.11 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.42 / $1,818.35 / $3,639.74
| Facility | | $830.42 | $1,818.35 | $3,639.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.54 / $1,700.86 / $1,748.24
| Professional | | $1,555.54 | $1,700.86 | $1,748.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Facility | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $2,056.76
| Professional | | $1,713.97 | $1,713.97 | $2,056.76 |