- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,449.43 / $1,487.12 / $1,764.67
| Facility | | $1,449.43 | $1,487.12 | $1,764.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.61 / $1,507.41 / $2,012.52
| Professional | | $1,209.61 | $1,507.41 | $2,012.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,703.95 / $2,889.21 / $5,543.01
| Facility | | $2,703.95 | $2,889.21 | $5,543.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.81 / $1,526.81 / $2,130.37
| Professional | | $1,526.81 | $1,526.81 | $2,130.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $1,626.03 / $2,183.10
| Professional | | $1,547.24 | $1,626.03 | $2,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.97 / $1,408.01 / $2,137.40
| Professional | | $1,130.97 | $1,408.01 | $2,137.40 |