- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,423.62 / $1,423.62 / $1,503.71
| Facility | | $1,423.62 | $1,423.62 | $1,503.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $1,263.08 / $1,665.83
| Professional | | $645.61 | $1,263.08 | $1,665.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.44 / $2,067.95 / $2,067.95
| Facility | | $1,857.44 | $2,067.95 | $2,067.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.43 / $1,671.50 / $1,685.57
| Professional | | $1,403.43 | $1,671.50 | $1,685.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,567.57
| Facility | | $173.31 | $1,082.51 | $1,567.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.91 / $1,082.51 / $1,806.70
| Professional | | $169.91 | $1,082.51 | $1,806.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.11 / $972.51 / $1,550.32
| Professional | | $766.11 | $972.51 | $1,550.32 |