- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.62 / $1,655.27 / $2,150.23
| Facility | | $1,624.62 | $1,655.27 | $2,150.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.88 / $1,682.10 / $2,312.65
| Professional | | $1,404.88 | $1,682.10 | $2,312.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,024.27 / $3,542.55 / $5,902.06
| Facility | | $3,024.27 | $3,542.55 | $5,902.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.05 / $1,718.05 / $2,477.98
| Professional | | $1,718.05 | $1,718.05 | $2,477.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $2,004.80
| Facility | | $1,815.81 | $1,815.81 | $2,004.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,815.81 / $1,935.74
| Professional | | $1,325.54 | $1,815.81 | $1,935.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.11 / $1,508.89 / $2,359.38
| Professional | | $1,208.11 | $1,508.89 | $2,359.38 |