- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,609.84 / $1,643.16 / $2,283.71
| Facility | | $1,609.84 | $1,643.16 | $2,283.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.57 / $1,713.59 / $2,476.67
| Professional | | $1,313.57 | $1,713.59 | $2,476.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.43 / $3,921.91 / $5,882.86
| Facility | | $2,941.43 | $3,921.91 | $5,882.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.10 / $1,788.71 / $2,816.39
| Professional | | $1,770.10 | $1,788.71 | $2,816.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $2,096.41
| Facility | | $1,902.78 | $1,902.78 | $2,096.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,902.78 / $2,126.15
| Professional | | $1,389.03 | $1,902.78 | $2,126.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.40 / $1,508.36 / $2,327.36
| Professional | | $1,304.40 | $1,508.36 | $2,327.36 |