- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,559.25 / $1,643.36 / $2,006.40
| Facility | | $1,559.25 | $1,643.36 | $2,006.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.33 / $1,623.15 / $2,457.29
| Professional | | $1,375.33 | $1,623.15 | $2,457.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.14 / $3,301.52 / $5,668.14
| Facility | | $2,767.14 | $3,301.52 | $5,668.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.68 / $1,972.92 / $2,645.52
| Professional | | $1,747.68 | $1,972.92 | $2,645.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.98 / $1,721.98 / $1,721.98
| Facility | | $1,721.98 | $1,721.98 | $1,721.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.05 / $1,721.98 / $2,019.28
| Professional | | $1,257.05 | $1,721.98 | $2,019.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,123.22 / $3,674.38 / $3,674.38
| Facility | | $3,123.22 | $3,674.38 | $3,674.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.70 / $1,613.57 / $2,246.78
| Professional | | $1,145.70 | $1,613.57 | $2,246.78 |