- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,175.67 / $1,248.02 / $1,772.56
| Facility | | $1,175.67 | $1,248.02 | $1,772.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.39 / $1,248.02 / $1,808.73
| Professional | | $952.39 | $1,248.02 | $1,808.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.66 / $1,631.66 / $2,175.31
| Professional | | $1,631.66 | $1,631.66 | $2,175.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,893.38 / $3,234.55 / $4,546.60
| Facility | | $1,893.38 | $3,234.55 | $4,546.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.21 / $1,544.47 / $1,544.47
| Professional | | $1,291.21 | $1,544.47 | $1,544.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,904.78 / $1,904.78 / $1,904.78
| Facility | | $1,904.78 | $1,904.78 | $1,904.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $1,207.83
| Facility | | $1,207.83 | $1,207.83 | $1,207.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $1,207.83 / $1,207.83
| Professional | | $881.72 | $1,207.83 | $1,207.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.55 / $1,055.55 / $1,055.55
| Facility | | $1,055.55 | $1,055.55 | $1,055.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.89 / $1,085.24 / $1,600.40
| Professional | | $642.89 | $1,085.24 | $1,600.40 |