- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.75 / $1,600.51 / $1,938.52
| Facility | | $1,579.75 | $1,600.51 | $1,938.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.34 / $1,661.72 / $2,285.71
| Professional | | $1,311.34 | $1,661.72 | $2,285.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.17 / $3,807.96 / $6,355.38
| Facility | | $2,951.17 | $3,807.96 | $6,355.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.30 / $1,715.30 / $2,706.06
| Professional | | $1,715.30 | $1,715.30 | $2,706.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,050.41
| Facility | | $2,050.41 | $2,050.41 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $3,373.13
| Professional | | $1,496.80 | $1,496.80 | $3,373.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.50 / $1,512.51 / $2,255.71
| Professional | | $1,266.50 | $1,512.51 | $2,255.71 |