- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,589.28 / $1,615.16 / $1,929.83
| Facility | | $1,589.28 | $1,615.16 | $1,929.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.24 / $1,637.19 / $2,167.19
| Professional | | $1,289.24 | $1,637.19 | $2,167.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,881.93 / $3,269.91 / $6,020.27
| Facility | | $2,881.93 | $3,269.91 | $6,020.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.37 / $1,722.19 / $2,454.90
| Professional | | $1,654.37 | $1,722.19 | $2,454.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.13 / $2,084.13 / $2,084.13
| Facility | | $2,084.13 | $2,084.13 | $2,084.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $2,084.13 / $2,221.79
| Professional | | $1,521.41 | $2,084.13 | $2,221.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.80 / $1,815.91 / $2,070.48
| Facility | | $1,058.80 | $1,815.91 | $2,070.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.16 / $1,491.53 / $2,135.36
| Professional | | $1,145.16 | $1,491.53 | $2,135.36 |